486804234-4-16-2025-21-AS-SSTN-DFSTA5-20250416143258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804234
Report Date: 04/16/2025
Date Signed: 04/16/2025 02:33:23 PM

Document Has Been Signed on 04/16/2025 02:33 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:	ANICA HOMECARE		FACILITY NUMBER:	486804234
ADMINISTRATOR/ DIRECTOR:	VILLEGAS, ART		FACILITY TYPE:	740
ADDRESS:	1001 BRETON DRIVE		TELEPHONE:	(707) 344-0839
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 6		CENSUS: 4	DATE:	04/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:41 AM
MET WITH:	Indivduals Liezyl Leano and Rudolfo Capili and Licencee Art Villegas		TIME VISIT/ INSPECTION COMPLETED:	02:45 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 09:30 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and was greeted by individuals Liezyl Leano and Rodolfo Capili who were not associated to the home through Guardian. At approximately 9:45 AM licensee Art Villegas arrived for tour of facility. Facility is a Residential Care Facility for the Elderly (RCFE) licensed for six (6) residents with four (4) residents in care. Facility has a Hospice waiver for three (3), with two (2) hospice residents currently in care. Facility is approved for 6 non-ambulatory residents. At approximately 10:00 AM, LPA 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. Facility has required posters up in main hallway.Fire extinguishers were last inspected 04/2024 and were observed to be fully charged . Water temperatures measured between 105F and 120F (at 116.2F) as required by title 22 regulation. LPA 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 medicines and other items that could pose a risk were locked. Tall weeds and grasses were observed primarily in the front of the property and side yards that could potentially increase a fire hazard as they dry out and licensee given a technical advisory to mow down the tall weeds and grasses before they dry out to limit the potential for fire hazard. An exterior shed was unlocked and observed to be full of extra-supplies and hardware. Continued 809C...

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025

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 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: ANICA HOMECARE	FACILITY NUMBER: 486804234
	VISIT DATE: 04/16/2025

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...

LPA observed TVs, books, patio with ramps, seating and sunshade accessible to residents.

Disaster drills were last conducted 02/2025

At approximately 11:30 AM LPA conducted a review of six (6) individual and staff records. Two (2) individuals observed performing direct resident care were not associated though Guardian and not cleared to work at the facility, three (3) other staff members records had all requirements. A type A deficiency was assigned and a civil penalty in the amount $200 is being assess due to a violation of CCR 80066(a)(12)(B)

At approximately 12:30 PM LPA conducted review of four (4) of four (4) resident records. All required documentation was present. One (1) of four (4) resident records records were with a residents son and LPA needed to wait for copies of the record to be supplied, a technical violation was issued (Licensee shall ensure that a residents record are readily available to licensing staff at all times)

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 with licensee/administrator

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 04/16/2025 02:33 PM - It Cannot Be Edited

Created By: Star Stevenson On 04/16/2025 at 01:37 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: ANICA HOMECARE	FACILITY NUMBER: 486804234
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87412(a)(13)(B)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following... (13) for employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or criminal record exemption as required by Section 87355(e). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of two (2) indivduals providing direct care, interview and record review the licensee did not comply with the section cited above in two (2) out of six (6) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2025
	Plan of Correction
1 2 3 4	Licensee to immediately send two (2) indivduals home (done on 04/16/2025) not associated to facility in GUARDIAN and cleared to work and to submit an email to CCL that indivduals (I1) and (I2) will not return to work until cleared to do so AND that the licensee understands the requirement that all indivduals be finger print and criminallly cleared and associated to a facility, before entering and working at the facility.

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: 04/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025

LIC809 (FAS) - (06/04)

Page: 6 of 6