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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800936
Report Date: 12/22/2025
Date Signed: 12/22/2025 03:22:42 PM

Document Has Been Signed on 12/22/2025 03:22 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:MC KINLEY CARE HOME #2FACILITY NUMBER:
486800936
ADMINISTRATOR/
DIRECTOR:		MCKINLEY/EVANSFACILITY TYPE:
735
ADDRESS:336 SAWYER STREETTELEPHONE:
(707) 557-4053
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 5DATE:
12/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Shaheed Evans, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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At approximately 12:40 PM, Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a required 1-year annual inspection and was greeted by Administrator Shaheed Evans. Facility is an Adult Residential Facility (ARF) with five (5) clients in care. Three (3) clients were away at day program and two (2) clients were present during inspection. Facility is serviced by vendor North Bay Regional Center (NBRC).

At approximately 1:00 PM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a two (2) story home, was a comfortable temperature, and passageways were free from obstructions. Facility's fire extinguisher was observed charged and last serviced 7/25. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Water temperatures in client bathrooms read at 117.1 degrees F and 116.7 degrees F which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, and paper products available for clients. Clients' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulation. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two (2) days of perishable food and seven (7) days of non-perishable foods, as well as an emergency water supply. Facility has an internet access devise and internet available to clients in care, and the phone was tested and operational during today's inspection. LPA observed three (3) locked sheds in the backyard which were inspected and observed to contain client belongings and overflow storage. Medication is centrally stored and locked. Administrator Certificate for Shaheed Evans certificate number 6012483735 expires 10/27. Facility conducts quarterly disaster drills, and the most recent drill was conducted 8/25. LPA observed facility's infection control plan and emergency disaster plan. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights.

Continued LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Elias Magdaleno
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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)
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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: MC KINLEY CARE HOME #2
FACILITY NUMBER: 486800936
VISIT DATE: 12/22/2025
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Continued from LIC809...


At approximately 1:40 PM LPA conducted a review of five (5) client records. LPA observed required documentation missing and Incidents Reports not submitted to CCL (deficiency cited, see LIC809D).

At approximately 2:50 PM LPA conducted review of two (2) staff records. No deficiency cited.

Updated copies of the following documents shall be submitted to CCL within 30 days of this visit:
LIC500 - Personnel Report
LIC308 - Designation of Responsibility
LIC610D - Emergency Disaster Plan
LIC400 - Affidavit Regarding Client Cash Resources
LIC402 - Surety Bond

Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC809D.

Exit interview conducted with Administrator, whose signature on form confirms receipt.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Elias Magdaleno
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2025 03:22 PM - It Cannot Be Edited


Created By: Elias Magdaleno On 12/22/2025 at 03:06 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: MC KINLEY CARE HOME #2
FACILITY NUMBER: 486800936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80061(b)
Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four (4) incident reports not submitted to CCL which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2026
Plan of Correction
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Adminsitrator stated they will submit Incident Reports to Community Care Licensing as per regulation cited by 5:00pm on Plan of Correction due date of 1/22/2026.
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in five (5) out of five (5) clients were missing required documentation from their files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2026
Plan of Correction
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Administrator stated they will submit requested documentation by 5:00pm on Plan of Correction due date of 1/22/2026.
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:
Elias Magdaleno
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


LIC809 (FAS) - (06/04)
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