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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804223
Report Date: 04/02/2025
Date Signed: 04/02/2025 01:18:33 PM

Document Has Been Signed on 04/02/2025 01:18 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:BEECH GROVE CARE HOMEFACILITY NUMBER:
486804223
ADMINISTRATOR/
DIRECTOR:		BAUTISTA, SARAH JANEFACILITY TYPE:
740
ADDRESS:219 REGENTS PARK DR.TELEPHONE:
(707) 977-8480
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 5DATE:
04/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Maria Delfino-Caregiver & Sarah J Bautista-licenseeTIME VISIT/
INSPECTION COMPLETED:
01:30 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 09:15 am, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and was greeted by caregiver Maria Delfino
Facility is a Residential Care Facility for the Elderly (RCFE) licensed for 6 residents with five (5) residents in care. Facility has a Hospice waiver for six (6), with 2 hospice residents currently in care, and is approved for all non-ambulatory residents.

At approximately 09:45 AM administrator Sarah Jane Bautista arrived.

At approximately 09:45 am, LPAs initiated a tour of the facility with licensee and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were last inspected 05/2024 and were observed to be fully charged . Water temperatures measured 115.5F and 116.5F. LPAs observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked.

A strong odor of urine was detected inside and just outside bedroom #5 with patient noted to have a history of incontinence and hospice care (deficiency cited)

LPAs observed at least a 2-day supply of a variety of healthy perishable foods, 7-day supply of non-perishable food, and emergency water supplies. In addition, a variety of snacks and fruits were observed to be set out for residents. Food was found to be stored in a safe manner with open items covered.
Continued 809C...
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2025
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 4
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 4
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: BEECH GROVE CARE HOME
FACILITY NUMBER: 486804223
VISIT DATE: 04/02/2025
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 809...
Facility has both a backup battery wall and generator, LPA observed a piano, TVs, books, patio with ramps, seating and sunshade accessible to residents. Licensee was advised to ensure that tall green grasses were cut to reduce fire hazard as grasses dry out. Disaster drills were last conducted 12/04/2024,

At approximately 11:15 AM LPA conducted a review of five (5) staff records. All 5 staff had required criminal clearance, health records and educational training.

At approximately 11:45 AM LPA conducted review of five (5) resident records. All required documentation was present.

At approximately 12:00 PM LPA and Licensee Bautista conducted a spot check of medication and medication records with records observed to be accurately kept. Medications were observed to be centrally stored and locked.

A copy of current liability insurance was obtained


Licensee/Administrator to submit updates of the following documents by 05/02/2025
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan - updated (if needed) and signed and dated
LIC 308 Designation of facility responsibility.

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.

This report was reviewed with Licensee/Administrator Sarah Bautista and Appeal rights were given.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/02/2025 01:18 PM - It Cannot Be Edited


Created By: Star Stevenson On 04/02/2025 at 12:43 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: BEECH GROVE CARE HOME
FACILITY NUMBER: 486804223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation/smell inside and just outside bedroom #5 and record review that resident is incontinent the licensee did not comply with the section 876259(b)(3) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2025
Plan of Correction
1
2
3
4
Licensee/Administrator to ensure that the odor coming from bedroom #5 room is inspected to find where and why the resident's room smells of urine odors and ensure the resident's room, and facility are free from incontinent odors/urine odors. Submit how the resident's room was cleaned, if anything (matress or other) was repaired or cleaned and submit a maintenance plan to keep room #5 free of incontinent odors. POC due 04/09/2025
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4