486803967-5-5-2026-21-AS-ECOS-DTSSP2-20260505140225

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803967
Report Date: 05/05/2026
Date Signed: 05/05/2026 02:02:43 PM

Document Has Been Signed on 05/05/2026 02:02 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:	LONGSPUR MANOR		FACILITY NUMBER:	486803967
ADMINISTRATOR/ DIRECTOR:	ANGELES, JANNE		FACILITY TYPE:	735
ADDRESS:	1107 LONGSPUR DR		TELEPHONE:	(415) 939-4491
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY: 4		CENSUS: 4	DATE:	05/05/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:10 AM
MET WITH:	Janne Angeles-Adminstrator		TIME VISIT/ INSPECTION COMPLETED:	02:15 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	Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection visit and was greeted by staff Miguen Bedruz and Maureen Abarico. Administrator (admin) Janne Angeles arrived shortly after. Facility is an Adult Residential Facility with a fire clearance approved for capacity of four (4) clients. There are currently 4 clients in care. Two were attending day program and two were present at facility during visit. Upon arrival, LPA checked Guardian Roster and found that client's 1:1 (S1) was not associated to facility roster (Deficiency Cited, see 809D). LPA had conversation with administrator that all staff must be associated to facility, including staff from outside agencies and ensure that they are fingerprinted. LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed inside facility. All required postings were in a highly visible area. Clients have access to outdoor use with outdoor exits and walkways unobstructed. All bedrooms found to have required furnishings. Water temperatures in client accessible bathrooms read within the allowable range of 105 to 120 degrees F per Title 22 Regulations. LPA observed a supply of clean linens, hygiene, and paper products available for clients. LPA observed at least a 2-day supply of perishable and 7- day supply of non-perishable food and water. Facility kitchen, refrigerators and freezers were clean. Snacks accessible to clients. Toxins are stored in a locked and inaccessible to clients. Emergency food and water observed. Fire extinguishers were charged and last inspected on 6/24/2025. Carbon and fire alarms were tested and operational. Disaster Drills are recorded and conducted monthly. First aid kits observed and phone accessible for clients. continued to 809C....

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026

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: LONGSPUR MANOR	FACILITY NUMBER: 486803967
	VISIT DATE: 05/05/2026

NARRATIVE

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continued from 809....

LPA reviewed 4 client records. All documentation was present and physicians reports and IPP up to date.
LPA reviewed 3 staff records. All required documentation was up to date.

LPA did medication check and observed Centrally Stored Medication Log to be up to date.

P&I is being handled for clients although there is currently no cash for any clients.

Updated copies of the following documents to be submitted within 30 days of visit to CCL to update facility file:

LIC400- Cash Resources
LIC500- Personnel Report (Retrieved during visit)
LIC308- Designation of Responsibility
Liability Insurance
Surety Bond

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted and read with administrator.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/05/2026 02:02 PM - It Cannot Be Edited

Created By: Ethel Contreras On 05/05/2026 at 01:44 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: LONGSPUR MANOR	FACILITY NUMBER: 486803967
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80019(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review the licensee did not comply with the section cited above in that staff (S1) was not associated to facility roster which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/08/2026
	Plan of Correction
1 2 3 4	Staff was associated to roster through Guardian. The facility will submit LIC9098 self-certification form certifying that they will monitor their facility roster regularly to prevent staff not been associated to the facility timely.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:

	Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026

LIC809 (FAS) - (06/04)

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