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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801218
Report Date: 02/27/2025
Date Signed: 02/27/2025 02:37:06 PM

Document Has Been Signed on 02/27/2025 02:37 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:DOVER VALLEY RESIDENTIAL CARE HOMEFACILITY NUMBER:
486801218
ADMINISTRATOR/
DIRECTOR:		CECILIA JUANILLOFACILITY TYPE:
740
ADDRESS:752 ROSEMARY COURTTELEPHONE:
(707) 427-1105
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
02/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Edward Gadia, House ManagerTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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At approximately 12:30 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by facility Staff. Edward Gadia, House Manager was contacted via telephone and arrived at approximately 12:45 PM. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for three (3), and is approved for 6 non-ambulatory residents. Facility does not currently have any Hospice residents in care.

At approximately 1:00 PM, LPA initiated a tour of the facility with House Manager and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were observed locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPA inspected two locked shed in the backyard which contained care equipment, holiday decorations, tools, and chemicals. LPA observed residents watching TV or reading in the common area and in their bedrooms. LPA observed games available to residents and House Manager states staff take the residents in the yard for exercise and facility staff discuss current events with residents daily. Facility does not have an internet access device designated for resident use, but House Manager agrees to purchase one immediately to bring the facility into compliance with regulation. Facility has internet service available to residents in care and the telephone was tested an operational during inspection.

Continued on LIC809-C...
Bethany MoellersTELEPHONE: (707) 588-5040
Julie FlorioTELEPHONE: (707) 588-5026
DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
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 2
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: DOVER VALLEY RESIDENTIAL CARE HOME
FACILITY NUMBER: 486801218
VISIT DATE: 02/27/2025
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Continued from LIC809C...

Facility's fire extinguisher was observed charged and was last serviced 07/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills, and the most recent drill was conducted 12/2024. LPA observed the facility's infection control plan, several first aid kits, PPE, and emergency supplies. Facility has a generator for emergency preparedness. LPA reviewed facility's emergency disaster plan last updated 02/2024.

House Manager stated they would like to update the facility Administrator to himself. Also, House Manager states that facility may be submitting an application for change of ownership within the next month. LPA discussed what needs to be submitted to CCL by the Licensee for this change to occur. LPA will return at a later date to complete the annual inspection. LPA will review resident files, staff files, and medications and medication logs during that visit. Facility does not manage P&I.

Required Change of Administrator Documents:

  • LIC 308 (Designation of Facility Responsibility)
  • Active and Current Administrator Certificate
  • First Aid Certificate
  • LIC 500 (Personnel Report)
  • LIC 501 (Personnel Record)
  • LIC 503 (Health Screening Report - personnel)
  • Proof of Negative TB test
  • LIC 9182 (Criminal Record Exemption Transfer Request)
  • LIC 508 (Criminal Record Statement)
  • Copy of Driver's License or Passport that is not expired
  • Statement signed by Licensee requesting Change of Administrator

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC610D - Emergency Disaster Plan (updated)

No deficiencies were cited during inspection.
Exit interview conducted with House Manager whose signature on form confirms receipt.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC809 (FAS) - (06/04)
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