486803740-3-30-2026-21-AS-SSTN-DSNTNS-20260330145313

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803740
Report Date: 03/30/2026
Date Signed: 03/30/2026 02:53:23 PM

Document Has Been Signed on 03/30/2026 02:53 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:	KALUSUGAN HOMES - BOXWOOD		FACILITY NUMBER:	486803740
ADMINISTRATOR/ DIRECTOR:	LEWIS-BARRETO, ANNABELLE		FACILITY TYPE:	735
ADDRESS:	2592 BOXWOOD LANE		TELEPHONE:	(707) 439-1816
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 4		CENSUS: 3	DATE:	03/30/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:35 PM
MET WITH:	Kayla Barreto - Designation of Facility Responsibility (RP)		TIME VISIT/ INSPECTION COMPLETED:	03:05 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 12:35 PM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and placed a call to licensee Annabelle Lewis-Barreto who arranged for her daughter and co-operator Kayla Barreto to arrive at approximately 1:05 PM. Facility is an Adult Residential Facility with Developmentally Disabled Clients in care. LPA was informed that Three (3) out of 3 clients were away at day program. At approximately 1:15 PM, LPA initiated a tour of the facility and observed the following: Facility was a comfortable temperature and passageways were free from obstructions and home was free from odors. Water temperature in clients' bathrooms measured between 105 F and 120 degrees as required by title 22 regulation. LPA observed facility has all required signage. LPA observed a supply of clean linens available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies/knives and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods and a supply of bottled water. Medications were centrally stored and locked. There is outdoor space for clients and the grounds are safe, clean and orderly. LPA observed a locked wooden shed in the backyard which is used solely as an office by Licensee and Administrator. In addition, LPA observed that a second side yard plastic shed was locked and full of Durable Medical Equipment and supplies. In addition, LPA observed a locked and empty travel trailer stored on the side of the house in the front yard, which is stored here at the facility by Licensee and Administrator but remains locked at all times and is for their personal use only. Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026

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: KALUSUGAN HOMES - BOXWOOD	FACILITY NUMBER: 486803740
	VISIT DATE: 03/30/2026

NARRATIVE

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Continued from LIC809
Facility is observed to have a piano, exercise equipment, television, games, plush toys, movies, outside shaded areas, as well as, additional emergency food and excess water in the garage.

The facility is hardwired. Fire extinguishers were charged and inspected January 2026. Smoke and Carbon Monoxide detectors were tested and operational during inspection.

LPA observed the facility's infection control plan, first aid kit, and emergency disaster plan which are all in compliance with regulation.

At approximately 1:45 PM RP counted out P & I money where were found to be secure and administered per title 22 regulation.

At approximately 02:00 PM five (5) staff files and three (3) client files were reviewed. All staff have current required First Aid certificates, and all have current CPR as well as medical and TB clearance and educational training. Three (3) of 3 client files were observed to have all required documentation.

LPA observed medications centrally stored and locked per title 22 regulations.

Licensee was advised that an update on the LLC's efforts to return to good standing with the Franchise Tax Board is due to Community Care Licensing by 04/05/2026

LPA requests the following documents to update the facilities file:

updated LIC500 Personel Roster
updated LIC610D (did personnel changes require a change?)
updated LIC308 Designation of Facility Responsibility

No deficiencies are cited.

Report was review with RP, whose signature denotes receipt.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026

LIC809 (FAS) - (06/04)

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