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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804287
Report Date: 02/03/2026
Date Signed: 02/03/2026 02:21:52 PM

Document Has Been Signed on 02/03/2026 02:21 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:PASITOS RESIDENTIAL - ELISA'S HOMEFACILITY NUMBER:
486804287
ADMINISTRATOR/
DIRECTOR:		ELISEO, ALDRINFACILITY TYPE:
735
ADDRESS:300 MONO DRIVETELEPHONE:
(650) 483-8133
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 4CENSUS: 2DATE:
02/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Jay Miranda-Lead Staff/House ManagerTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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At approximately 11:30 Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required 1-year facility inspection. Administrator unable to attend visit but granted Lead Staff/House Manager Jay Miranda to sign today's visit. LPA reviewed LIC308 and confirmed Jay Miranda as facility designee (admin). Facility is an Adult Residential Home approved for 4 clients which 2 can be ambulatory and 2 non-ambulatory. Facility is a one-story 5 bedroom home with 2 rooms vacant, one office/staff room and 2 rooms in use by clients. One client was attending day program and other client at an outing during visit. Facility had first client move in August 18, 2025.

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 and outside perimeters of facility. All required postings were visible. All bedrooms were observed to have clean linens, night stand, chair and light. Facility kitchen, refrigerators and freezers were clean. Snacks accessible to clients. Expiration dates noted in food and toxins are inaccessible to clients. LPA observed at least 7-day supply of non-perishable food. A 2-day supply of perishable foods was observed to be lacking. Frozen meats, eggs and ham were observed. However, fresh vegetables and fruits not observed in refrigerator (Technical Violation given). Sharps and knives were locked and inaccessible to clients. Canned goods were observed. Emergency water observed. LPA advised admin to separate everyday canned goods from emergency canned goods.

Bathroom accessible to clients had bath bats and paper towels. Water temperature measured within regulation at faucets accessible to clients. Fire extinguishers were charged and inspected on 12/2024. Carbon and fire alarms were tested and operational.
Continued onto 809C...
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2026
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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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: PASITOS RESIDENTIAL - ELISA'S HOME
FACILITY NUMBER: 486804287
VISIT DATE: 02/03/2026
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Continued from 809....

Disaster Drills are recorded and conducted quarterly, last drill conducted on 09/27/2025, LPA advised admin that disaster drill should have been conducted before or on 1/27/2026 (Technical Advisory given). Telephone accessible and functioning for client use.

LPA reviewed 2 of 2 client records. All documentation was present and physicians reports up to date. ID Emergency and Information form missing for S1 (Technical Advisory given).

LPA reviewed 4 Staff records. All required documentation was up to date.

LPA did medication spot check for all 2 clients and observed Centrally Stored Medication Log to be up to date and accurate.

Facility does not currently handle client's P&I monies.

Updated copies of the following documents to be submitted within 30 days of visit to CCL to update facility file:
LIC400- Cash Resources
LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance
Surety Bond

No deficiencies given during todays visit.

Exit interview conducted and read with administrator.

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

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
LIC809 (FAS) - (06/04)
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