<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804132
Report Date: 03/27/2026
Date Signed: 03/27/2026 12:02:04 PM

Document Has Been Signed on 03/27/2026 12:02 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:IMAGINE AT UNIONFACILITY NUMBER:
486804132
ADMINISTRATOR/
DIRECTOR:		PUNZALAN, VIRGINAFACILITY TYPE:
735
ADDRESS:830 UNION AVETELEPHONE:
(818) 642-3943
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
03/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
12:20 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
At approximately 09:45 AM, Licensing Program Analyst (LPA) Stevenson arrived unannounced to conduct a required 1 Year visit and met with caregiver Arlene Miller who called licensee/administrator Virginia Punzalan who arrived at approximately 10:15 AM to further assist with today's required inspection.

Facility is an Adult Residential Home that provides care and assistance for adults with disabilities. Facility has an approved fire clearance and capacity for 4 ambulatory clients. Upon arrival, LPA was informed that there were four (4) clients in care with all 4 clients present at time of inspection.

At approximately 10:10 AM, LPA conducted a walk-though of the facility with licensee. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction and facility without odors. Facility has emergency lighting. Facility is a one story building with 4 client bedrooms, 1 client and 1 staff bathroom, and common areas. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins and sharps were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use.

An exterior locked shed was observed through windows to contain various automotive tools and extra supplies. Facility has an outdoor Pergola to provide shade and clients take guided or walk on their own in nearby downtown.

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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)
Page: 2 of 3
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: IMAGINE AT UNION
FACILITY NUMBER: 486804132
VISIT DATE: 03/27/2026
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
26
27
28
29
30
31
32
Continued from LIC809
Water temperatures for all sinks available to clients in care were measure between 105f to 120F as required by Title 22 regulations.

Facility knows to perform an Emergency and Disaster drill a minium of every 3 months and the facilities last Emergency drill was conducted 03/09/2026. Facilities fire extinguisher was last inspected 02/2026 and observed to be fully charged. Facility maintains emergency "go packs" for each client in care.

At approximately 11:00 AM, LPA reviewed five (5) staff files and observed all 5 to have required documents.

At approximately 11:15 AM four (4) of 4 client files were reviewed and all 4 have the required documentation per title 22 regulations.

At approximately 11:25 AM Medicines were observed to be centrally stored and their administration accurate.

Facility now manages client cash resources and a new LIC400 Affidavit Regarding Client Cash resources was obtained today along with evidence of Surety bonding appropriate to the LIC400.

LPA recently obtained an updated copy of LIC500 Personnel Roster on 03/25/2026

LPA obtained the following documents during today's inspection:

  • Affidavit regarding Client/Resident Cash Resources (LIC 400)
  • Surety bond appropriate to Client Cash Resources
  • LIC9020 Register of Facility Clients


Licensee is asked to submit the follow document by 04/26/2026 to update facility file
  • Updated LIC610D Emergency Disaster Plan

No deficiencies cited today. Exit interview conducted with licensee Virginia Punzalan.
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: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC809 (FAS) - (06/04)
Page: 3 of 3