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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804273
Report Date: 02/20/2025
Date Signed: 02/20/2025 05:46:03 PM

Document Has Been Signed on 02/20/2025 05:46 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:M & M CARE HOMEFACILITY NUMBER:
486804273
ADMINISTRATOR/
DIRECTOR:		SALVANI, MARIA AFACILITY TYPE:
735
ADDRESS:2046 ORANGE TREE WAYTELEPHONE:
(707) 434-9912
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
02/20/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Maria Salvani, LicenseeTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
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At approximately 12:30 PM, Licensing Program Analysts (LPAs) Julie Florio and Elias Magdaleno arrived unannounced to conduct a pre-licensing inspection and were greeted by facility staff. Maria Salvani, Licensee/Applicant was contacted via telephone and arrived about 20 minutes later. This pre-licensing inspection is being conducted for a change of ownership for an existing sole proprietorship facility identified as M&M Care Home #486801838 to a corporation ownership structure. Facility is an Adult Residential Facility (ARF). Fire Clearance has been approved for 4 ambulatory clients. Licensee/Applicant is currently in partnership with North Bay Regional Center (NBRC).

At approximately 1:00 PM, LPAs initiated a tour of the facility and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. However, LPAs observed a love seat and couch as well as a dinning room table, hutch, and chairs blocking the exit door leading from the garage to the side yard of the facility. LPAs informed Licensee that the furniture shall be removed prior to license approval. LPAs observed required postings including the CCL Complaint Poster and Personal Rights for Individuals with Developmental Disabilities. Water temperatures in clients' bathrooms measured 124 and 126 degrees F, which is above the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs requested Licensee submit a 3-day water temperature log to CCL prior to approval of license to verify the facility has been brought into compliance with regulation. LPA observed a supply of at least two (2) days of perishable and seven (7) days of nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was a supply of cleaning products, linens, hygiene products and paper products available for clients.

Facility has emergency lighting. Facility has an Infection Control plan and Emergency Disaster Plan on file.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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 9
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: M & M CARE HOME
FACILITY NUMBER: 486804273
VISIT DATE: 02/20/2025
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...continued from LIC809...

Emergency lighting and supplies, and a first aid kit were observed. Smoke and carbon monoxide detectors were tested and operational during today's inspection. Fire extinguisher was observed charged and was last inspected 01/2025. Facility phone was observed inoperable during today's inspection. Licensee understands they need to bring the existing facility into compliance before this facility's license can be issued. The backyard features paved walkways and a patio with a shaded area for client outdoor use. Windows, screens, and blinds are all found to be in good repair and facility exits are clearly identified.

At approximately 2:00 PM, LPAs conducted file review and observed the following: six (6) of six (6) staff files were reviewed. Staff 1 (S1), Staff 3 (S3), and S5 (S5) were missing the LIC503 - Health Screening. S1 and Staff 4 (S4) were missing proof of negative TB results. S1, S2, and S5 were missing proof of current first aid training. Lastly, S5 was missing their LIC501 - Personnel Record. Four (4) of Four client records were reviewed. Client 1 (C1), Client 2 (C2), Client 3 (C3), and Client 4 (C4) were missing a LIC627 - Consent for emergency medical treatment from their files. Additionally, C2, C3, and C4 were each missing a LIC625 - Appraisal Needs and Service Plan from their files. All remaining required documents were present in clients' files. Medication was observed to be centrally stored and secure. P&I was stored and maintained in compliance with regulation.

The Licensee are the only staff currently associated to the facility. Licensee has been informed of association and staff transfer process.

Component III orientation was conducted with the Licensee/Applicant at facility. Licensee/Applicant conveyed knowledge and understanding of Title 22 regulations. The pre-licensing evaluation has been completed. License will be granted upon proof of correction of the identified deficient areas of concern noted during today's inspection. These items have been cited under the current facility's license.

Exit interview conducted with Licensee/Applicant, whose signature on this document confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
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