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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804007
Report Date: 10/07/2025
Date Signed: 10/07/2025 12:17:23 PM

Document Has Been Signed on 10/07/2025 12:17 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:INFINITI CARE HOME #1FACILITY NUMBER:
486804007
ADMINISTRATOR/
DIRECTOR:		FROLIAN DEVERAFACILITY TYPE:
735
ADDRESS:607 TRAVIS BLVDTELEPHONE:
(707) 771-1516
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
10/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:43 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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At approximately 09:45 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and met with caregiver Ester KIng who called Administrator Froilan Devera.

Facility is an Adult Residential Facility with four (4) ambulatory clients in care and all were away at day programs during my visit. Facility is vendorized with North Bay Regional Center (NBRC).

At approximately 10:15 AM, Administrator Froilan Devera arrived and LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, free of odors and passageways were free from obstructions. Water temperature 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, hygiene, incontinent care, and paper products available to clients in care. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Food was stored per title 22 regulations with left-over food/meats labeled with the date they were placed in new ziplock bags or tupperware and no instances of expired canned foods were observed this year. Facility uses magnet locks for some of their cabinets containing laundry detergents, which LPA observed stored on the refridgerator in the kitchen where it was accessible to clients in care and a technical violation issued was issued. Administrator and Licensee agreed to ensure that the magnets shall remain inaccessible to clients in care at all times.

Facility's fire extinguisher was observed charged and was last serviced 07/2025. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducted its most recent emergency disaster drill 7/2025. LPA observed facility's infection control plan and emergency disaster plan which was last updated 5/2025. LPA observed a supply of PPE, emergency supplies, a first aid kit, and a lantern for emergency preparedness. Administrator states the facility does not have a backup generator.
Continued on LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2025
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: INFINITI CARE HOME #1
FACILITY NUMBER: 486804007
VISIT DATE: 10/07/2025
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Continued from LIC809
Medications were centrally stored and locked. There is outdoor space for activities in the backyard. LPA observed an activity schedule, games, and crafting supplies and was informed that each client has their own internet access device. Facility has internet available to clients in care and the phone was tested an operational.

At approximately 10:45 AM, LPA reviewed 4 staff files and 4 client files. 4 of 4 staff files reviewed had all the required documentation per regulation, including proof of current First Aid and CPR training. 4 of 4 client records reviewed had all required documentation per regulation.

Licensee states facility coordinates the residents' medical and dental appointments as needed and provides transportation to and from these visits. LPA reviewed residents' P&I records and P&I records indicated a mis-match between money records and actual money on hand with a small amount of extra client money on hand. Licensee was advised to maintain an accurate record of P&I money at all times and a technical violation was cited. Medications and medication records were are all maintained in compliance with regulation.

LPA obtained updated LIC610D today for facility file.

Licensee to provide updated copies of the following by 11/06/2025
1)LIC500 Personnel Record
2)Updated LIC400 Affidavit Regarding Client Cash Resources to reflect a smaller amount insured by their Surety bond
3)Updated Lease agreement (Lease on file expired May of 2025)

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 Administrator 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: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC809 (FAS) - (06/04)
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