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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803614
Report Date: 08/04/2026
Date Signed: 08/04/2026 04:45:41 PM

Document Has Been Signed on 08/04/2026 04:45 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:OAKWOOD MEMORY & SENIOR CAREFACILITY NUMBER:
486803614
ADMINISTRATOR/
DIRECTOR:		REYNALDO GUTIERREZFACILITY TYPE:
740
ADDRESS:1025 OAKWOOD AVENUETELEPHONE:
(707) 643-0473
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 30CENSUS: 12DATE:
08/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Reynaldo Gutierrez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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At approximately 1:15 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with care staff. Reynaldo Gutierrez, Administrator was contacted via telephone and arrived at the facility at approximately 2:30 PM. Facility is a Residential Care Facility for the Elderly (RCFE) with 12 residents in care. Facility serves memory care residents, has a Hospice waiver for 10, and approval for 10 bedridden residents. Facility has a Department approved waiver for a secured perimeter which was granted in 08/2016.

At approximately 2:30 PM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a on story building and was a comfortable temperature. LPA observed chairs and outdoor furniture stored on the patio outside of room three. Facility staff moved the chairs immediately and agreed to ensure the facility is operating in compliance with regulation moving forward. The remaining passageways were observed free from obstructions. Facility has the required postings in the main common areas which are accessible to the public. However, LPA did not observe an activity calendar or menu posted. Administrator agreed to post these immediately to ensure the facility is operating in compliance with regulation. 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 paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. However, LPA observed multiple instances of furniture and window covering that were in disrepair, such as missing or broken dresser drawers, missing or broken knobs or handles on furniture drawers, curtains and blinds ripped or broken, and couches and chairs with torn fabric. Administrator agreed to either repair or replace the observed items before LPA returns to the facility to finish this annual inspection. Closets containing cleaning supplies and other items that could potentially pose a risk to residents in care were observed locked.
Continued on LIC809C...
Bethany Moellers
Julie Florio
DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2026
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: OAKWOOD MEMORY & SENIOR CARE
FACILITY NUMBER: 486803614
VISIT DATE: 08/04/2026
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Continued from LIC809C...
Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. LPA informed Administrator and kitchen staff that food shall be properly labeled and stored to ensure quality healthy food is being served to residents in care. Both agreed to ensure compliance with regulation moving forward. Medications were observed centrally stored and locked. There are outdoor shaded seating areas for activities. LPA observed residents engaged in activities in common areas. Facility has internet service and an internet access device designated for resident use.

Facility's last fire inspection was conducted 1/2026. Fire extinguishers were observed fully charged, two were last inspected 01/2026, one was last inspected 7/2025, and one was missing an inspection tag. Administrator agreed to have the two extinguishers missing proof of inspection within the last year inspected immediately. Emergency Disaster Plan was reviewed and updated 08/2026. Staff 1 (S1) states that facility conducts quarterly disaster drills however was unable to provide any proof of a drill being conducted since 7/2025, (see LIC809D). Facility has a back up generator for emergency preparedness. Facility has emergency lighting and a first aid kit.

Residents' families mostly coordinate medical and dental appointments as well as transportation to and from appointments but facility will assist as needed and utilizes a third party transportation service when needed. Facility does not handle P&I cash resources.

LPA will return at a later date to review staff and resident files, medications, and medication records.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 - Personnel Roster (updated to include administrators schedule)
  • Proof of current liability insurance in the required amounts
  • LIC610E Emergency Disaster Plan (updated)

Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the deficiencies by the plan of correction date and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator whose signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2026 04:45 PM - It Cannot Be Edited


Created By: Julie Florio On 08/04/2026 at 04:27 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: OAKWOOD MEMORY & SENIOR CARE
FACILITY NUMBER: 486803614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on record review, the licensee did not comply with the section cited above in ensuring that the required logs are mainitaned and available for inspection by the Departmetn for the required quartlery disaster drills which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2026
Plan of Correction
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Administrator to submit proof of a current diaster drill being conducted in the facility on every shift to the Department by the POC due date of 09/04/2026.
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:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2026


LIC809 (FAS) - (06/04)
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