486804229-9-19-2025-21-AS-ADEZ-DLNS47-20250919133217

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804229
Report Date: 09/19/2025
Date Signed: 09/19/2025 01:32:57 PM

Document Has Been Signed on 09/19/2025 01:32 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:	SAN LORENZO HOME		FACILITY NUMBER:	486804229
ADMINISTRATOR/ DIRECTOR:	CUNNINGHAM, IRENE		FACILITY TYPE:	735
ADDRESS:	601 SAN LORENZO STREET		TELEPHONE:	(707) 330-9314
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 4		CENSUS: 3	DATE:	09/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:25 AM
MET WITH:	Administrator, Irine Cunningham		TIME VISIT/ INSPECTION COMPLETED:	01:50 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	On 09/19/2025 at approximately 09:25AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Adult Residential Facility (ARF). LPA was greeted by Administrator, Irine Cunningham. Admin Richard Cunningham arrived shortly before inspection started. The facility has an approved fire clearance and capacity for 4 residents which 2 may be non-ambulatory. Upon arrival, LPA was informed that there were 3 residents in care and 2 staff members on-site. Facility is a 1 story building with 4 resident bedrooms, 1 staff bedroom, 2 bathrooms, and common spaces. At approximately 10:35AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared, however 1 out of 2 staff members weren’t associated on Guardian with the facility per regulation. Administrator stated they thought S1 was on the Guardian, and they faxed S1’s fingerprint clearance paperwork to the CCL long time ago. Administrator contacted CCL Santa Rosa office to associate the S1 on the Guardian during the inspection (Technical Advice Given). At approximately 11:05AM, LPA and Administrator 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 were in the process of cleaning up rooms at the time of this inspection. Toxins are stored in a locked cabinet under sink and in the laundry room. Water temperature measured 105.6 degrees F and 109.4 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Continued on LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025

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 09/19/2025 01:32 PM - It Cannot Be Edited

Created By: Ali Deniz On 09/19/2025 at 12:44 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: SAN LORENZO HOME	FACILITY NUMBER: 486804229
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80026(h)(1)

Safeguards for Cash Resources, Personal Property and Valuables

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 2 [(objects) persons P& I money ledger was comingled which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2025
	Plan of Correction
1 2 3 4	Administrator agrees to revise the ledger and submit the updated ledger to CCL by plan of correction due date 09/30/2025.

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.

	Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:

	Ali Deniz
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025

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: SAN LORENZO HOME	FACILITY NUMBER: 486804229
	VISIT DATE: 09/19/2025

NARRATIVE

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Continued from LIC809...
Fire Extinguishers found to be last charged on 08/01/2024 and was indicating proper pressure with gauges in green zone at the time of visit. Administrator stated fire extinguishers inspection scheduled for next week. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in a cabinet closet next to the dining room.
At approximately 12:05PM, LPA reviewed 2 resident records and found 2 of 2 residents have current care plans, signed admission agreements, and physician's report on file. LPA reviewed 2 staff records. 2 of 2 records did contain documentation of completed training records as required. Evidence of current first aid and CPR training were current. LPA was presented with proof of current CPR & 1^st Aid certification for the whole staff. Administrator Certificate is for Irine Cunningham #7035956735 expires 12/04/2026.
LPA reviewed the facility emergency disaster plan. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 12/03/2024. Administrator stated that they forgot documenting their latest disaster drill (Technical Advice Given).
P&I's are kept on a locked facility room; facility responsible for all client’s P&I and money; facility had P&I and ledgers available during the visit. P& I money ledger was comingled (See LIC809-D page).

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 09/30/2025:
- LIC 308 Designation of Facility Responsibility
- LIC 500 Personnel Summary
- LIC 610 Emergency Disaster Plan (If changed)
- LIC 9020 Register of Facility Client’s/Resident’s
- Copy/Proof of Updated Certificate of Liability Insurance
- LIC402 Surety Bond

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: 09/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025

LIC809 (FAS) - (06/04)

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