486803713-12-2-2025-21-AS-SSTN-DNYU2A-20251202141138

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803713
Report Date: 12/02/2025
Date Signed: 12/02/2025 02:11:52 PM

Document Has Been Signed on 12/02/2025 02:11 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:	RUTHIE'S HOME		FACILITY NUMBER:	486803713
ADMINISTRATOR/ DIRECTOR:	ROBIN BRANDON		FACILITY TYPE:	735
ADDRESS:	3789 CLAY BANK RD		TELEPHONE:	(707) 673-2047
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 4		CENSUS: 4	DATE:	12/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Lead staff-Raquel Cistac		TIME VISIT/ INSPECTION COMPLETED:	02:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 09:40 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and was greeted by lead staff Raquel Cistac. Raquel advised that their newest client of 5 day, (C1) was having a behavioral expression, with a documented history Self Injurious Behaviors (SIB). LPA observed 2 and 3 staff members at times helping (C1) to avoid injuring themselves. LPA noted that C1 had scratches on their face, as well as a prominent black/purple black eye. LPA inquired as to if, Community Care Licensing (CCL) was notified within 24 hours by phone or writing of the events leading up to and the injuries, to which the licensee indicated 24 hour notice was not made. LPA spoke by phone with the licensee who promised to submit a Special Incident Report (SIR) within 7 days as required by regulation. (Technical Violation issued) Facility is an Adult Residential Facility (ARF) with four (4) ambulatory clients in care. One client was away with family, while another was away at day programming and two were present during today's inspection. Facility is vendorized with North Bay Regional Center (NBRC). At approximately 11:20 AM, LPA initiated a tour of the facility with lead staff and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to clients. Clients' bedrooms were inspected and observed to have all of the appropriate furnishings as outlined in Title 22 regulations. Facility was noted to feature 2 large bathrooms with walk-in showers. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. In addition, LPA observed emergency go-bags, as well as, emergency kits with food that will last 5 years. Continued on LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025

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: RUTHIE'S HOME	FACILITY NUMBER: 486803713
	VISIT DATE: 12/02/2025

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Continued from LIC809...
Medications were centrally stored and locked. There is space in the backyard for activities. Facility has one pop-up umbrella for summertime shade and licensee was advised of best practice to ensure a permanent shade source for all clients in care. (Technical Advisory issued). LPA observed a treadmill and seated exercise bike available to clients that could use them.

Facility's fire extinguishers were observed charged and were last serviced July 2025. Smoke and Carbon Monoxide detectors were tested and operational during inspection. The last disaster drill was performed 6 months ago on June 19, 2025 and licensee was advised of the newer requirement to conduct quarterly disaster drills (Technical Violation issued)

At approximately 12:20 PM LPA reviewed five (5) staff records and found all 5 to have the required documentation.

At approximately 1:00 PM LPA reviewed four (4) of 4 client files and found that new client C1 was missing current evidence of a conservator signed Consent for Emergency Medical Treatment, as well as, Personal Rights (Technical Violation issue)

Updated copies of the following are to be immediately submitted to CCL to make lead staff member the administrator including:
1)LIC308 Designation of Facility Responsibility for Lead Care staff member to become Administrator.
2)Statement from the Corporate Board requesting that the lead Care staff member become Administrator.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC500 - Personnel Report (updated)
Affidavit Regarding Client Cash Resources (updated)
LIC610D Emergency Disaster Plan (updated)
LIC9020 Client Roster

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

Exit interview conducted with Lead Staff Member and Appeal rights were given. Signature on form confirms receipt.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025

LIC809 (FAS) - (06/04)

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