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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804098
Report Date: 02/27/2025
Date Signed: 02/27/2025 02:56:50 PM

Document Has Been Signed on 02/27/2025 02:56 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 #3FACILITY NUMBER:
486804098
ADMINISTRATOR/
DIRECTOR:		DEVERA, ALEHAFACILITY TYPE:
735
ADDRESS:353 ARLINGTON CIRCLETELEPHONE:
(707) 673-2078
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
02/27/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Aleha DeveraTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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At approximately 12:20PM, Licensing Program Analyst (LPA) Stevenson arrived unannounced to continue a Required 1 Year annual inspection visit and met with licensee Julie Martuscello.

LPA were informed there were currently 1 client in care 3 at day program and 4 staff members on site.

At approximately 12:35 PM , LPA observed and took additional pictures of living structure in the garage with walls and lockable door not on their fire/facility sketch. Licensee reports no permit for structure. LPA observed made bed, pillows, night stand, luggage, desk with hygiene products/toothbrush, dresser (additional pictures taken)

At approximately 12:50PM Administrator Aleha Devera arrived to the Facility.

At approximately 1:00 PM LPA reviewed the Facility's Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPA reviewed staff files and medication. Staff files were all found to be well organized, thorough and contained the required documentation. Staff have current first aid/CPR certification and TB clearance. Medications was observed to be centrally stored and secure. P&I money was accounted for and not co-mingled.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, or repeat violations within a 12 month period, may result in a civil penalty assessment.

**An immediate Civil Penalty in the total amount of $500 is being assessed for the observed un-permitted structure built in the garage that is not indicated on available and posted fire/facility sketch, which is a fire clearance violation and immediate health, safety, and/or personal rights violation to persons in care (See LIC421IM)**.

Exit interview conducted with Administrator, whose signature on form confirms receipt. Appeal rights provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
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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Document Has Been Signed on 02/27/2025 02:56 PM - It Cannot Be Edited


Created By: Star Stevenson On 02/27/2025 at 02:23 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: INFINITI CARE HOME #3
FACILITY NUMBER: 486804098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in ensuring the faclity's fire clearance accurately reflects the current facilty layout, as evidenced by an un-permitted, structure obsered in the garage with bed, dresser, night stand and hygene products which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Licensee to submit a new facility sketch which accurately reflects the facility's current layout to include the new structure in the garage to CCL by POC due date 02/28/2025
Licensee to self certify to CCL that additional room in garage will not be used for any purpose until room is inspected by local Fire Marshall with a new fire clearance by 02/28/2025
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Star Stevenson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
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