480111090-5-20-2026-21-AS-CCOO-DU7TDJ-20260518143824

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 480111090
Report Date: 05/18/2026
Date Signed: 05/20/2026 04:43:18 PM

Document Has Been Signed on 05/20/2026 04:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	GILCREST GROUP HOME, THE		FACILITY NUMBER:	480111090
ADMINISTRATOR/ DIRECTOR:	CHERYL DAVIDSON		FACILITY TYPE:	735
ADDRESS:	447 GILCREST		TELEPHONE:	(707) 563-5543
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY: 9		CENSUS: 7	DATE:	05/18/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:38 AM
MET WITH:	Cheryl Davidson, Admin		TIME VISIT/ INSPECTION COMPLETED:	02:53 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by designee, Administrator Cheryl Davidson arrived later. Facility currently has seven (7) residents in care none of which are currently on hospice. Administrator certificate #7011528735 expired 5/15/26. However, Administrator showed LPA the proof of delivery and USPS receipt for mailing off certificate renewal package. Package mailed in on 5/5/26. LPA verified with Officer of the Day at CCL that Cheryl Davidson is on the Pending-Renewal. At approximately 10:15am LPA and designee toured the building and grounds. LPA and Admin discussed having at least a 2 day supply of perishable and 7 day supply of non-perishable food. Currently, facility does not have quantity of food that would allow for 2 day supply of perishable and 7 day supply of non-perishable food for seven residents (deficiency cited, see 809D). LPA did not observe any disinfectants or cleaning supplies accessible to residents in care. All other cleaning products and laundry soaps are located with staff. Residents ask staff for laundry pods in order to do their laundry. Staff then give one pod per load of laundry. . All bedrooms were equipped with lighting, night stand, and chest of drawers. Extra hygiene products and linens were available. Water temperature in sinks measured at 122 degrees F in the bathroom used by staff and residents, 118.5 degrees F in room #1, and 113.9 degrees F in the and 126.3 degrees F in the back bathroom. Two temperatures are not within the allowable range of 105 to 120 degrees F. Facility had maintenance person present and they immediately lowered temperature. LPA measure water again in Continued on 809C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/18/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GILCREST GROUP HOME, THE	FACILITY NUMBER: 480111090
	VISIT DATE: 05/18/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

back bathroom and water temperature read 110.7 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 10/15/25. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted on 12/18/25. LPA discussed with staff be sure to conduct drills quarterly.

Facility does not manage P&I for residents.

At approximately 12:30pm LPA conducted a review of four (4) out of four (4) staff files. No deficiencies cited.
At approximately 1:00pm LPA conducted review of five (5) out of seven (7) resident files. Files complete. No deficiencies cited.

At approximately 1:45pm and LPA, designee, and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. LPA discussed with Admin and designee regulation requirements for PRN medications, PRN MARs, Centrally Stored Medication Log (CSML), signed doctors orders, discontinuation orders for any medications that are discontinued.

LPA and Admin discussed Emergency Disaster Plan. Licensee confirmed no updates needed.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/18/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/20/2026 04:43 PM - It Cannot Be Edited

Created By: Christi Coppo On 05/18/2026 at 02:26 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GILCREST GROUP HOME, THE	FACILITY NUMBER: 480111090
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85076(d)(1)

Food Service

(d) The licensee shall meet the following food supply and storage requirements: (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation, the licensee did not comply with the section cited above in that facility did not have quantity of food to meet regulation, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/01/2026
	Plan of Correction
1 2 3 4	Facilty to submit one week meal plan for 7 residents and submit grocery receipt showing foods required to prepare meals indicated on meal plan by plan of correction due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:

	Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/18/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

LIC809 (FAS) - (06/04)

Page: 4 of 4