<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800471
Report Date: 05/19/2025
Date Signed: 05/19/2025 01:19:56 PM

Document Has Been Signed on 05/19/2025 01:19 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:MARGARETS FAMILY HOMEFACILITY NUMBER:
486800471
ADMINISTRATOR/
DIRECTOR:		MROZ, MARGARETFACILITY TYPE:
735
ADDRESS:566 FIESTA CT.TELEPHONE:
(707) 421-0714
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 2DATE:
05/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Margaret Mroz, LIcensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:28 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
At approximately 11:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct a required 1-year annual inspection and was greeted by Margaret Mroz, Licensee/Administrator. Facility is an Adult Residential Facility with Developmentally Disabled Clients in care. Facility licensed for 4 clients. LPA was informed that there are 2 clients in care, and both were away at their day programs.

At approximately 11:50AM, LPA and Licensee initiated a tour of the facility and observed the following: Facility is a two-story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods. Facility has supplies enough to operate for more than 72 hours in an emergency. However LPA observed an emergency water supply was low and licensee agreed to order more emergency water supply. There is outdoor space for activities. There is a pool in the backyard, which is gated and locked. There are two sheds in the back yard, which were observed to be used for storage and projects, and both were locked. LPA observed puzzles and a supply of games for clients. Licensee states that clients attend outings and go on vacations with her and her family.

The facility is hardwired. Fire extinguisher was last serviced March 2025. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular disaster drills quarterly, and the most recent drill was conducted 05/19/2025. Licensee states facility has a back-up generator if one is needed. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in dining room in a cabinet.

Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2025
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 3
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 3
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: MARGARETS FAMILY HOME
FACILITY NUMBER: 486800471
VISIT DATE: 05/19/2025
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
Continued from LIC809

At approximately 12:45PM, LPA reviewed 2 resident records and found 2 of 2 residents have current physician's reports, care plans, signed admission agreements, and physician's orders on file. Medication records are thorough and contained physician's orders for each resident.

At approximately 12:55PM, LPA reviewed 2 staff records. 2 of 2 records did contain documentation of completed training records, health screening as required. Evidence of current first aid and CPR training were presented. Administrator Certificate is for Margaret Mroz #7034446735 expires 09/10/2026.

P&I's are kept in a locked filed cabinet in the facility dining room; facility responsible for all client’s P&I and money; facility had P&I and ledgers available during the visit. P&I money not commingled, and ledgers are current on 05/19/2025.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 10 days of this visit:

LIC 308 Designated
LIC 500 Personnel Summary
Copy/Proof of Updated Certificate of Liability Insurance

No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.

Exit interview conducted. Copy of report provided to Licensee. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3