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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803285
Report Date: 08/21/2025
Date Signed: 08/21/2025 12:15:55 PM

Document Has Been Signed on 08/21/2025 12:15 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:C & F SENIOR CARE HOMEFACILITY NUMBER:
486803285
ADMINISTRATOR/
DIRECTOR:		FOJAS, LINAFACILITY TYPE:
740
ADDRESS:1120 SONGWOOD ROADTELEPHONE:
(707) 246-0867
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 4DATE:
08/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:23 AM
MET WITH:Lina Fojas (Administrator)TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator/Licensee, Lina Fojas. There are currently residents with a diagnosis of dementia and receiving hospice services. Annual fees are current.

LPA/staff toured the home at around 9:30am and found the home to be at a comfortable temperature with all exits free from obstruction. Residents have a call button to alert staff and call bell button was tested and operational during inspection. Exit doors have auditory alarms to alert staff. Smoke detectors and carbon monoxide detectors were tested and operational. The fire extinguisher located in the kitchen was observed charged and serviced as of July 2025. Last disaster drill was conducted on 6/27/25. Water temperature measured 116.4, 113.7 and 117.1 which is within regulation of 105-120 degrees. Bathrooms have required non-skid surfaces and grab bars. However, two out of three faucets located in resident's bathrooms were spraying water all over the place. LPA discussed with Administrator the issue (technical violation issued). Cleaning products and knives are stored in locked cabinets in the kitchen. There was enough food supply for seven days of non-perishables foods and two day supply of perishables food. Food appeared to be handled, stored and prepared in a healthful manner. Residents' medications are stored in kitchen locked cabinet and closet. The facility doesn't handle cash resources. Required postings observed. The facility is a two level home, but all resident's bedrooms are located on the first level of the home, no evacuation chair needed. Contact information reviewed. Continue on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2025
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 8
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: C & F SENIOR CARE HOME
FACILITY NUMBER: 486803285
VISIT DATE: 08/21/2025
NARRATIVE
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Continued from LIC809...
No snacks were provided during LPA's visit, LPA discussed with the Licensee the importance of providing snacks to residents in care between meals (technical violation issued). Some residents were observed watching tv and others were out of the facility.

During tour of the facility LPA/Licensee observed cameras located through the facility common areas. Licensee stated that cameras located in common areas were not included in all resident's admission agreements, LPA instructed Licensee to prepare an addendum to their admission agreements reflecting the use of surveillance cameras without audio in common areas. Licensee agreed to elaborate an addendum to admission agreements.

LPA initiated file review at 10:00 am. LPA reviewed four residents files and three staff files. One out of four residents (R1) needs half bed rails doctor's order. During LPA's visit home health nurse came to the facility and Licensee requested half bed rails order. One out of four resident's (R2) needs service plans needs to be updated. LPA had a conversation with Licensee due to R2 has a history of bedsores and it is concerning that they do not have a care plan reflecting their care needs. Also, there are two residents with special diet and LPA observed same food been served for all residents. After inquiring with staff it was determined that residents in hospice has a separate meal been served. Licensee agreed to follow resident's specialized diet (technical advisory issued). All three out of three staff do have current First Aid/CPR certificates and 20 hours of additional required training. Administrator Certificate for Administrator Lina Fojas #7001660740 expires on 10/05/2025. Medications and medication records were reviewed. Licensee provided updates of the following documents: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and copy of liability Certificate.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Licensee and a copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/21/2025 12:15 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/21/2025 at 11:53 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: C & F SENIOR CARE HOME
FACILITY NUMBER: 486803285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 4 residents care plan were not updated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
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Licensee will review regulation 87463(a),then they will update the reappraisals for resident R2 and send to CCL the LIC9098 form ensuring that care plans were updated by POC due date to clear deficiency.
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Licensee observation, interview and record review, the licensee did not comply with the section cited above in 4 out of 4 admission agreements were not updated indicating the use of surveillance cameras in the common areas which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
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Licensee agrees to create an addendum indicating the use of surveillance cameras in the common areas. The addendum will be signed by residents or their responsible parties by POC due date to clear deficiency and self-certification form LIC9098 will be sent to CCL as proof of correction.
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:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/21/2025 12:15 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/21/2025 at 11:53 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: C & F SENIOR CARE HOME
FACILITY NUMBER: 486803285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation and interview the faciltiy failed to provide Dr. order for postural support for R1 which poses a potential health and safety risk to resident in care.
POC Due Date: 08/28/2025
Plan of Correction
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Licensee agrees to obtain 1/2 bed rail order for R1's file and submit self-certification form LIC9098 to CCL by POC due date. If unable to obtain an order, Licensee agrees to remove the bed rails and submit photo to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2025


LIC809 (FAS) - (06/04)
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