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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803925
Report Date: 09/22/2026
Date Signed: 09/22/2026 11:43:04 AM

Document Has Been Signed on 09/22/2026 11:43 AM - 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:AMEERA CAREFACILITY NUMBER:
486803925
ADMINISTRATOR/
DIRECTOR:		ELSA MAGAOAYFACILITY TYPE:
740
ADDRESS:2568 BOXWOOD LANETELEPHONE:
(925) 818-6415
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 5DATE:
09/22/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator-Elsa MagaoayTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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At approximately 9:15 AM Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and was greeted by Administrator Elsa Magaoay. Facility is a Residential Care Facility for the Elderly (RCFE) with five (5) residents in care. All residents were present during today's inspection. Facility has a hospice waiver for three (3), a bedridden fire clearance for one (1) Resident that can be served in bedroom #2. Facility currently has two (2) hospice residents in care.

At approximately 9:35 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, without odors and passageways were free from obstructions. Each resident room features an additional air purifier. In addition the facility has padded reclining chairs for each resident, a large television and piano.

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 clean linens and paper products available to residents. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations.
Licensee advised that the door into bedroom #1 can only be used by the resident of room #1 and cannot be used by staff or other residents as a passage into the adjoining bathroom available to the resident of bedroom #1

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.

Continued on LIC809-C...
Bethany Moellers
Star Stevenson
DATE: 09/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2026
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: AMEERA CARE
FACILITY NUMBER: 486803925
VISIT DATE: 09/22/2026
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Continued from LIC809

There is a large raised and fenced patio with wide a ramp into the backyard for dinning and activities. Licensee advised to move a shade umbrella our purchase a new shade umbrella for the upper patio deck where residents are more likely to spend time. LPA observed two locked sheds in the backyard which were observed to be have additional PPE, supplies and hardware.

At approximately, 10:15 AM, LPA conducted file review of all five (5) resident files and observed that five (5) of five (5) resident files reviewed contained all the required documents per Title 22 regulations.

Four (4) employee files were observed to have all required paperwork including evidence of 20 hour of annual education, 1st aid/CPR, TB clearance and criminal record clearance.

At approximately 10:55 AM, LPA reviewed medications and medication administration and observed medications to be centrally stored and secure and their administration accurate.

Faciltiy does not manage Resident money.

Facility knows to conduct an Emergency and Disaster Drill every 3 months and last conducted a drill in July 2026.

LPA obtained the following documents today to update the facility file including:
1)LIC500 Personnel Record
2)LIC9020 Updated Register of Facility Residents
3)LIC610E Emergency Disaster Plan
4)Facility Sketch

LPA asks that licensee submit evidence of updated Liability insurance once current expires in November 2026

No deficiencies cited during today's inspection.

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: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026
LIC809 (FAS) - (06/04)
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