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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801931
Report Date: 09/11/2025
Date Signed: 09/11/2025 02:15:44 PM

Document Has Been Signed on 09/11/2025 02:15 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:DUNGARVIN CALIFORNIA LLCFACILITY NUMBER:
486801931
ADMINISTRATOR/
DIRECTOR:		NOWLIN, JERAMIEFACILITY TYPE:
775
ADDRESS:310 E MONTE VISTA AVE STE ATELEPHONE:
(707) 449-3722
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 45CENSUS: 39DATE:
09/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:03 AM
MET WITH:Jeramie Nowlin-Program DirectorTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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At approximately 10:00am, Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection and was greeted by Program Director (PD) Jeramie Nowlin. Facility is an Adult Day Program with a fire clearance approved for 25 ambulatory and 25 non-ambulatory participants. Day programs hours are 8:30am to 2:30pm, Monday through Friday.

LPA and PD toured the building and grounds. The facility was found to be clean and at a comfortable temperature. All exits were clear from obstruction . Participants were observed to be engaged in activities such as arts and crafts, coloring and electronic usage. Multiple participants were out on outings. LPA observed two different monthly calendar of outings, events, and activities planned. PD stated there are 6 different groups in which the participants help create the calendar each month by choosing what they would like to participate in. Lunch is not provided; participants bring their own lunch. LPA observed clean kitchen with sharps locked as cooking classes are available.

Water temperature in sink accessible to participants in care measured at 126.1,115.3 and 109.7 degrees F which is not within the allowable range of 105 to 120 degrees F. Facility has three water heaters. PD advised to ensure all water temperatures test within the allowable range of 105-120 degrees Fahrenheit per Title 22 regulations. Chemicals stored in locked in closet. 3 out of 3 fire extinguishers were last inspected 10/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility fire drills are conducted monthly with last drill conducted on 8/15/2025. Emergency disaster drills are conducted quarterly with last drill conducted on 8/08/2025. Facility has 5 vans in total, 4 were in transportation during visit. Facility had extra PPE, emergency kits with emergency food and water supply for 30 days.
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NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2025
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: DUNGARVIN CALIFORNIA LLC
FACILITY NUMBER: 486801931
VISIT DATE: 09/11/2025
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Continued from 809C...

At approximately 12:15, LPA conducted file review for 6 participants, all required documentation was present.

LPA conducted file review for 5 staff, all had the required documentation per regulation.

LPA conducted medication spot check. All medication is centrally stored and locked for 4 participants. LPA observed Centrally Stored Log not up to date for one participant. PD updated log and LPA had conversation to ensure all logs are kept up to date at all times.

Facility does not handle client cash resources.

At approximately 1:30, participants arrived from outing and LPA inspected 5 of 5 vans. All had required first aid kits and fire extinguishers.

LPA collected the following forms during visit:
- LIC 500 Personnel Report
- LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for clients)

No deficiencies cited during this inspection

Exit interview conducted with Program Director, copy of report given.
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC809 (FAS) - (06/04)
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