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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804114
Report Date: 02/27/2025
Date Signed: 02/27/2025 11:53:53 AM

Document Has Been Signed on 02/27/2025 11:53 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:GOOD SAMARITAN CARE HOMEFACILITY NUMBER:
486804114
ADMINISTRATOR/
DIRECTOR:		DE GUZMAN, JANOLYN R.FACILITY TYPE:
740
ADDRESS:506 LABRADOR WAYTELEPHONE:
(650) 532-4317
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 6CENSUS: 5DATE:
02/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Juan "Miguel" Luis SantosTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
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At approximately 9:30 AM, Licensing Program Analysts (LPAs) Julie Florio and Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and were greeted by Staff 1 (S1). Administrator, Luningning "Nina" Sikat, was contacted and informed LPAs that Staff 2 (S2) would come to the facility to conduct the inspection with LPAs. S2 arrived at approximately 10:30 am. 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) and is approved for six (6) non-ambulatory residents.

LPAs were informed by a resident that another staff person was present in the facility. Subsequently, LPAs discovered Staff 3 (S3) located in the designated staff bedroom and were informed that S3 has been working in the facility for six (6) days without a criminal record clearance or having been associated to the facility in the guardian system as required per Title 22 regulation, (see LIC809D and LIC421BG).

LPAs will return at a later date to complete the annual inspection.

Deficiencies 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.

**An Immediate Civil Penalty in the total amount of $500 is being assessed for the observed uncleared staff present, working, and sleeping in facility, which is a criminal record clearance violation and immediate health, safety, and/or personal rights violation to persons in care, (see LIC421BG).**

Appeal rights were given. Exit interview conducted with S2 whose signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
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 11:53 AM - It Cannot Be Edited


Created By: Julie Florio On 02/27/2025 at 11:23 AM
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: GOOD SAMARITAN CARE HOME
FACILITY NUMBER: 486804114

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 2 instances where staff (S3) was present in facility did not have a criminal background clearance 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 self-certification that S3 will not work or reside in facility until a criminal background clearance is obtained for them to CCL by POC dues date 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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
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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