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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803251
Report Date: 04/15/2025
Date Signed: 04/15/2025 03:21:49 PM

Document Has Been Signed on 04/15/2025 03:21 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:MASONIC GUEST HOME IIFACILITY NUMBER:
486803251
ADMINISTRATOR/
DIRECTOR:		LACAP, LEONIDAFACILITY TYPE:
740
ADDRESS:108 PINTO DRIVETELEPHONE:
(707) 644-3822
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
04/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Leonida Lacap, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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At approximately 9:10 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and was greeted by Administrator Leonida Lacap. Masonic Guest Home II is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a single story ranch house. The facility has an approved fire clearance for six (6) non-ambulatory residents. The facility has a Hospice Waiver for two (2) residents. Upon arrival, LPA was informed that there were six (6) residents in care and two (2) staff members on-site. At approximately 9:25 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 9:30 AM, LPA toured the facility with Administrator Lacap. All exits were clear and unobstructed. The facility's two (2) fire extinguishers were last serviced and tagged on 9/10/2024. Fire Department inspected and cleared the facility in March, 2024. The facility was sufficiently lighted. LPA inspected three (3) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Toxins were observed to be stored inaccessible to residents. Facility has an infection control plan as required. The facility has a required emergency disaster plan. Regulations' stipulate that the facility should be conducting fire and emergency drills quarterly. LPA observed that the last disaster drill was conducted on 12/1/2024. This deficiency will be cited. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements.

Continued on 809-C
Victoria BertozziTELEPHONE: (707) 588-5059
Robert FrankTELEPHONE: (707) 588-5026
DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2025
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: MASONIC GUEST HOME II
FACILITY NUMBER: 486803251
VISIT DATE: 04/15/2025
NARRATIVE
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...Continued from 809

Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational. At approximately 10:10 AM, LPA reviewed five (5) resident files. Four (4) of five (5) resident files were found to be missing various documentation. Resident one's (R1) file was observed to be missing signed personal rights and preplacement appraisal documents. Resident two's (R2) file was observed to be missing personal rights and an annual medical assessment. Resident three's (R3) file was observed to be missing an annual medical assessment. Resident 4's (R4) file was observed to not have reappraisals completed from 2021 to 2023. These deficiencies will be sighted. LPA reviewed three (3) staff files. Two (2) of three (3) staff files were found with all required documentation including First Aid and CPR certification and proper training documentation. Staff member S1's file was observed to be missing the LIC 503 Medical assessment and Tuberculosis (TB) test and current 1st Aid and CPR certification. These deficiencies will be cited. LPA spot checked Medication for three (3) residents. LPA observed all medications to be centrally stored, secure and with proper documentation. The facility does not handle resident’s monies for personal and incidental items.

Leonida Lacap’s Administrator Certification 7033434740 is current with an expiration date of 10/14/2025.

LPA requested the following documents be submitted to Community Care Licensing by 5/15/2025: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Proof of Liability Insurance

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.


Exit interview conducted. Copy of report, LIC-809Ds, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Administrator Lacap. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Robert FrankTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/15/2025 03:21 PM - It Cannot Be Edited


Created By: Robert Frank On 04/15/2025 at 01:57 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: MASONIC GUEST HOME II
FACILITY NUMBER: 486803251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that Staff member S1's file was observed to be missing the LIC 503 Medical assessment and Tuberculosis (TB) test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2025
Plan of Correction
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Licensee or Administrator will submit to Community Care Licensing a valid LIC 503 Medical Assessment and TB test for S1 by the POC due date of 5/15/2025.

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:
TELEPHONE: (707) 588-5059
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (707) 588-5026
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2025 03:21 PM - It Cannot Be Edited


Created By: Robert Frank On 04/15/2025 at 01:57 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: MASONIC GUEST HOME II
FACILITY NUMBER: 486803251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and record review, the licensee did not comply with the section cited above in Staff member S1's file was observed to be missing current 1st Aid and CPR certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2025
Plan of Correction
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Licensee or Administrator will submit to Community Care Licensing valid CPR and 1st Aid certification for S1 by the POC due date of 5/15/2025.
Type B
Section Cited
CCR
87468(b)(1)(A)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that the resident files for R1 and R2 did not contain signed Personal Rights documentation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2025
Plan of Correction
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2
3
4
Licensee or Administrator will submit to Community Care Licensing Signed Personal Rights documentation for R1 and R2 by POC due date of 5/15/2025.
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:
TELEPHONE: (707) 588-5059
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (707) 588-5026
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 04/15/2025 03:21 PM - It Cannot Be Edited


Created By: Robert Frank On 04/15/2025 at 01:57 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: MASONIC GUEST HOME II
FACILITY NUMBER: 486803251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above in that R1's file did not have a Pre-Placement Appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2025
Plan of Correction
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Licensee or Administrator will self certify that a Pre-Placement Appraisal will be completed for all new residents going forward by POC due date of 5/15/2025.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and record review, the licensee did not comply with the section cited above in that R4 did not have annual reappraisals done for 2021, 2022 and 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2025
Plan of Correction
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3
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Licensee or Administrator will self certify that Reappraisals will be completed as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition for all residents going forward by POC due date of 5/15/2025.
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:
TELEPHONE: (707) 588-5059
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (707) 588-5026
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 04/15/2025 03:21 PM - It Cannot Be Edited


Created By: Robert Frank On 04/15/2025 at 01:57 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: MASONIC GUEST HOME II
FACILITY NUMBER: 486803251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that R2 and R3 did not receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment have which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2025
Plan of Correction
1
2
3
4
Licensee or Administrator will provide updated Medical Assessments for R2 and R3 and will self certify that they understand that all residents must receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. These are to be provided to Community Care Licensing by the POC due date of 5/26/2025
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that emergency drills are not being completed quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2025
Plan of Correction
1
2
3
4
Licensee or Administrator will submit to Community Care Licensing proof that an emergency drill has been completed by POC due date of 5/15/2025. Licensee or Administrator will also self certify that Emergency drills will completed quarterly going forward.
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:
TELEPHONE: (707) 588-5059
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (707) 588-5026
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
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