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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804246
Report Date: 08/05/2025
Date Signed: 08/05/2025 03:29:31 PM

Document Has Been Signed on 08/05/2025 03:29 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:4 SEASONSFACILITY NUMBER:
486804246
ADMINISTRATOR/
DIRECTOR:		MATHURIN, HERBYFACILITY TYPE:
735
ADDRESS:907 HARLEQUIN WAYTELEPHONE:
(415) 629-1205
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 5CENSUS: 3DATE:
08/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:37 AM
MET WITH:Jodian Allen-Designee of Responsibility TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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At 11:30am, Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct an annual inspection and met with designee of responsibility Jodian Allen, administrator Herby Mathurin was not able to be present during visit. Facility is an Adult Residential approved for 5 clients of which 2 are cleared for non-ambulatory. 1 bedroom approved for non-ambulatory. Facility currently has 3 clients in care.

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 inside facility. All required postings were in a highly visible area. Clients have access to outdoor use with outdoor exits and walkways unobstructed. LPA observed emergency exit to be locked. Staff told LPA that door is kept locked at night due to elopement and then unlocked again in the morning. LPA had conversation with staff that door cannot be locked at any time during the day or night.

All bedrooms in good repair. All bedrooms were observed to have clean linens, night stand, chair and light. Oral rinse was left out in client bedroom. LPA told staff that any prescribed medication must not be in clients bedrooms. LPA observed a strong odor coming from bedroom #3. Staff stated client refuses to change clothing and room is cleaned while client leaves facility due to behaviors. LPA observed staff cleaning room after client left the facility. LPA observed the room to had been clean and free of odor.

LPA observed at least a 2-day supply of perishable and 7-day supply of non-perishable food.
Facility kitchen, refrigerators and freezers were clean, and food was stored properly. LPA told staff that all food must had expiration dates noted. Toxins are stored in a locked cabinet and inaccessible to clients. Sharps and knives were locked in kitchen drawers.

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NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2025
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 3
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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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: 4 SEASONS
FACILITY NUMBER: 486804246
VISIT DATE: 08/05/2025
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Continued from 809....

Bathroom accessible to clients did not have required bath mat or paper towels. Staff stated paper towels not in bathroom due to client clogging toilet from overuse. Each client has their own hand towel in their room. Water temperature measured within regulation at 112.4 degree F at faucets accessible to clients. Fire extinguishers were charged and bought on 1/16/2025. Carbon and fire alarms were tested and operational. Disaster Drills are recorded and conducted. Last disaster drill done 4/12/2025.

LPA reviewed 4 of 4 client records and 4 Staff records, all documentation was present.

LPA conducted medication spot check and observed medication RX number to not be updated on one medication. LPA had conversation to keep all RX numbers up to date in all medication.

P&I is handled by clients and conservator.

Updated copies of the following documents to be submitted within 30 days of visit to CCL to update facility file:
LIC500- Personnel Report
LIC308- Designation of Responsibility (collected at facility)
Liability Insurance

No deficiencies given during todays visit.

Exit interview conducted.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC809 (FAS) - (06/04)
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