486804177-2-12-2026-21-AS-SSTN-DR8W2S-20260212155445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804177
Report Date: 02/12/2026
Date Signed: 02/12/2026 03:54:55 PM

Document Has Been Signed on 02/12/2026 03:54 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:	Q & R RESIDENTIAL FACILITY LLC		FACILITY NUMBER:	486804177
ADMINISTRATOR/ DIRECTOR:	PEARSON, ROSHAWN		FACILITY TYPE:	735
ADDRESS:	2707 WHITE ALDER CT		TELEPHONE:	(707) 759-6774
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 5		CENSUS: 4	DATE:	02/12/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:10 PM
MET WITH:	Deajah Jefferson -Designation of Facilty Responsibility (RP)		TIME VISIT/ INSPECTION COMPLETED:	04:05 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 1:10 PM Licensing Program Analysts (LPAs) Stevenson and Florio arrived unannounced to conduct a Required - 1 Year Inspection. LPAs met wtih caregiver Deajah Jefferson, who has Designation of Facility Responsibility (RP). RP called licensee Roshawn Pearson to advise of today's required inspection. Licensee Roshawn Pearson arrived at approximately 2:40 PM to further assist with today's inspection. One (1) of four (4) clients was home, and Three (3) of four (4) were away at the time of the inspection. At approximately 1:40 PM LPAs and RP toured the facility. Facility has an infection control plan as required. Fire clearance approval is for four (5) ambulatory clients. Licensee Pearson has stated that "although fire clearance is for 5 ambulatory clients, North Bay Regional Center has only cleared the home to have four (4) clients". Facility was found be a comfortable temperature, clean and without odors. LPAs observed missing kick plate below dishwasher and a loose door hinges of door leading into laundry room and a Technical Advisory for CCR 80087(a) was given for good repair of a facility. LPAs noted that laundry detergents and toxins are secured in a locked garage adjoining the laundry room. A fire evacuation chair purchased last year is not available at the upstairs stairwell in case of emergency and a Technical Violation of HSC 1565(f)(1) is being issued. RP notes that water temperatures fluctuate and water available to clients in care tested over the 120F allowed by regulation and signage indicating a warning that water maybe above 125F are not in place and a Technical Violation of CCR 80087(a) is being issued. Facility conducts quarterly emergency and disaster drills with last drills conducted on 01/15/2026 Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

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 6

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 6

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: Q & R RESIDENTIAL FACILITY LLC	FACILITY NUMBER: 486804177
	VISIT DATE: 02/12/2026

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
All exits were cleared and free of obstruction. Two Fire extinguishers were observed to be fully charged and last inspected March 2025. Combination smoke and carbon monoxide detectors throughout the home were found to be functional. Licensee has more than the required carbon monoxide detectors and was asked to remove one in the downstairs that is no longer functioning to reduce confusion during inspections.

Licensee does not currently handle P&I monies despite LIC400 Affidavit for Client Cash Resources and clients are noted to be able to mange their own cash resources or have family that help them. None of the clients in care are conserved.

LPA reviewed four (4) client files. Four (4) of (4) client files were found to have required documentation.

LPA reviewed five (5) staff files, four (4) of five staff were noted to have current 1st Aid and CPR and licensee reports a 5th has an appointment to renew their 1st Aid/CPR certification. All other required documents are present.

Medications are centrally stored and locked and the administration of medicines were observed to be accurate.

LPA is requesting the following forms be updated and submitted by 03/10/2026
· LIC 500 -Personnel Report
· LIC 610D- Disaster Plan
· LIC 308 - Designation of Responsibility (if changes)

Technical Violations and Advisories are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Licensee Roshawn Pearson and Appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

LIC809 (FAS) - (06/04)

Page: 3 of 6