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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804214
Report Date: 04/11/2025
Date Signed: 04/11/2025 02:06:08 PM

Document Has Been Signed on 04/11/2025 02:06 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:HUMUCARE INC - FIELDCREST AVEFACILITY NUMBER:
486804214
ADMINISTRATOR/
DIRECTOR:		BARRETT ADAMSFACILITY TYPE:
735
ADDRESS:2160 FIELDCREST AVENUETELEPHONE:
(714) 323-3822
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: 2DATE:
04/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Administrator Barrett AdamsTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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At approximately 09:15AM, Licensing Program Analyst (LPA) Ali Deniz made an unannounced annual inspection of this licensed adult care facility. LPA met with facility Administrator Barrett Adams. Licensee Olukemi Kuku arrived about an hour later. Administrator Barrett Adams weren’t present during this inspection. There is a total of 2 residents at facility, 1 of them was attending a day program
Facility is a 1-story building with 4 Resident bedrooms, 1 staff bedroom, and common spaces.

At approximately 10:45AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Staff was in the process of cleaning up the resident rooms at the time of this inspection. Toxins are stored in a locked housekeeping closet in the hallway. Water temperature measured within regulation between 105- and 120-degrees F at faucets accessible to residents. During the walk LPA/Licensee observed garbage bins in the resident shared bathroom did not have any cover or lid on them (Technical Advisory given). Fire extinguishers were inspected and charged on 03/09/2025. Carbon Monoxide and smoke detectors were present and operational. There was enough lighting in all common areas, resident rooms, and hallways.

During the medication review LPA observed medication was centrally stored and locked, however the medication records or log weren't filled for each medication on MAR log (See LIC809-D page).

At approximately 12:10PM, LPA reviewed 2 resident records and found to be in order and contained current and signed admission agreements and physician's orders on file.

Continued on LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2025
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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Document Has Been Signed on 04/11/2025 02:06 PM - It Cannot Be Edited


Created By: Ali Deniz On 04/11/2025 at 01:33 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: HUMUCARE INC - FIELDCREST AVE
FACILITY NUMBER: 486804214

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 2 out of 3 staff weren’t associated in the staff roster/guardian which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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Licensee agrees to update staff guardian list and will share the current staff roster with LIC500 before plan of correction date 04/18/2025
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

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 2 out of total count, the medication records weren't filled for each medication on centrally stored log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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Licensee agrees to update MAR and will share the centrally stared logs before plan of correction date 04/18/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Ali Deniz
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2025


LIC809 (FAS) - (06/04)
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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: HUMUCARE INC - FIELDCREST AVE
FACILITY NUMBER: 486804214
VISIT DATE: 04/11/2025
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Continued from LIC809...

At approximately 12:40PM, LPA reviewed 3 staff records. During staff file review LPA/Admin observed 2 of 3 staff weren’t associated in the staff roster on guardian web page. Licensee stated she never received her credentials to be able to associate the new staff into guardian webpage. However, S1 and S2 had fingerprint clearance in file (See LIC809-D page).

At approximately 1:05PM, LPA reviewed the facility emergency disaster plan with staff. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 02/17/2025.

LPA was presented with proof of current CPR & 1st Aid certification for staff. Administrator Certificate is for Barrett Adams #7029790735 expires 08/17/2025. P&I monies were documented, secure and not commingled.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (If there are any changes)
LIC 9020 Register of Facility Resident’s
Copy of Updated Certificate of Liability Insurance


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.

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC809 (FAS) - (06/04)
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