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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801888
Report Date: 09/01/2026
Date Signed: 09/01/2026 12:12:41 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/01/2026 12:12 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:JENSTEPH HOME CAREFACILITY NUMBER:
486801888
ADMINISTRATOR/
DIRECTOR:		AQUINO, RAFAEL V.FACILITY TYPE:
740
ADDRESS:736 ANITA CIR.TELEPHONE:
(707) 747-6659
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY: 6CENSUS: 4DATE:
09/01/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Administrator Rafael AquinoTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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At approximately 9:35 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced to conduct a Required- 1 Year visit, and met with caregiver Violeta Navarro who has Designation of Facility Responsibility (RP). RP called Licensees Rose Aquino, and Administrator Rafael Aquino who arrived at approximately 10:00 AM to further assist with today's required inspection. There are currently are four (4) residents in care. LPA observed two caregivers on duty upon admission into the facility.

Fire clearance approval is for six (6) non-ambulatory residents, there is no bedridden approval. Facility has an approved hospice waiver for one (1). Facility has an approved dementia plan of operation. Facility has a required infection control plan. Facility has an emergency disaster plan as required.

LPA toured the facility with Administrator Rafael. Facility was observed to clean, orderly and without odors. All postings were visible to all entering facility. Hot water was measured at 115.7. degrees Fahrenheit. All bathrooms had grab bars, and shower mats/non-slip flooring for resident use. Fire extinguisher was serviced and tagged as required on 04/2026. All exits were clear and free from obstruction. The bathrooms, resident rooms, hallways, and all common areas had sufficient lighting for residents' in care, and for use by residents. Facility had sufficient furnishings for resident use.

Backyard was free and clear of any hazards, and backyard fire exit path was clear and free of obstruction. The backyard features a shaded patio and furniture for residents' use. In addition facility has two thriving covered and exposed gardens. Two sheds were opened to reveal hardware and toxins locked up. Exit doors had auditory alarms.
Continued on LIC809C..
Bethany Moellers
Star Stevenson
DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2026
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: JENSTEPH HOME CARE
FACILITY NUMBER: 486801888
VISIT DATE: 09/01/2026
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Continued from LIC809
Food supply was sufficient and facility has a wide variety of fresh and frozen foods that are stored well. Facility had sufficient supply of cleaners, paper products, linens. and personal protective equipment (PPE).

LPA reviewed four (4) resident files and found all 4 needed updated Appraisal and Service Needs (ANS) plans for Residents R1, R2, R3 and R4 and a Technical Violation for violation of CCR 87463(a) which requires annual updates to ANS for residents.

LPA reviewed four (4) staff files. All staff had required criminal record clearance.
LPA notes that both primary care staff (S1 and S2) did not have evidence of current CPR training and a Type B citation for violation HSC 1569.618(c)(3) is cited, which requires that the facility have a caregiver with current CPR training on-site at all times.

Medicines were observed to be centrally stored and secure.

Facility does not manage Resident Cash Resources.

LPA requested the following documents be updated and submitted to CCL by 10/01/2026:
LIC500 - Personnel Report
LIC610 (9 pages) - Emergency Disaster Plan- if updates, submit copy to CCL
LIC9020 Roster of residents
Copy of Current Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator Rafael Aquino.

Appeal Rights provided to the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/01/2026 12:12 PM - It Cannot Be Edited


Created By: Star Stevenson On 09/01/2026 at 10:43 AM
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: JENSTEPH HOME CARE
FACILITY NUMBER: 486801888

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2026
Section Cited
HSC
1569.618(c)(3)

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(c)The facility shall employ, and the administrator shall...(3)Ensure that at least one staff member who has CPR training and first aide training is on duty and on the premises at all times. This paragraph shall not construed to require staff to provide CPR
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Licensee to self-certify they have read regulation HSC 1569.618(c)(3) and to provide proof of appointments for CPR training and/or valid CPR certificates for ALL for staff members by 09/11/2026.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2026


LIC809 (FAS) - (06/04)
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