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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804299
Report Date: 05/07/2026
Date Signed: 05/07/2026 01:43:33 PM

Document Has Been Signed on 05/07/2026 01:43 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:C&R CARE HOME, LLCFACILITY NUMBER:
486804299
ADMINISTRATOR/
DIRECTOR:		BAUTISTA, ROMULO NFACILITY TYPE:
740
ADDRESS:373 HERON WAYTELEPHONE:
(510) 750-2003
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 4DATE:
05/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Romulo Bautista-Administrator TIME VISIT/
INSPECTION COMPLETED:
02:05 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection and was greeted by administrator (admin) Romulo Bautista. Facility is an Adult Residential Care Facility for the Elderly with an approved fire clearance for capacity of 6 (six) residents. There are currently four (4) residents in care with one resident on hospice.

LPA toured the building and grounds which was found to be clean and at a comfortable temperature. LPA observed all walkways and exits to be unobstructed. All required postings were in a highly visible area. Fire extinguishers were last inspected 8/26/2025. Fire alarm and carbon monoxide alarms all tested and operational. Outdoor furniture accessible for resident use. Water temperature check measured within regulation at faucets accessible to residents within the allowable range of 105 to 120 degrees F. Resident bathrooms observed to have bath mat and grab bar. Disaster drills are being conducted monthly. All bedrooms were equipped with required furnishing. Facility had an ample supply of linens, towels and extra hygiene products for residents. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable foods. Emergency food and water was observed to meet the 72 hour emergency supply Facility kitchen, refrigerators and freezers were clean. Expiration dates were not noted in any food items found in refrigerator and freezer. LPA had conversation with admin that food needs to be properly labeled with expiration dates noted (Technical Violation given). Toxins are locked and inaccessible to residents. Sharps and knives were locked. Phone accessible for resident use.

LPA conducted a file review for 4 out of 4 residents. S1 and S2 did not have an updated medical assessment (MA). S1 last MA was completed in 2022 and S2 last MA was from 2023. (Deficiency Cited, See 809D).

continued to 809C...
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2026
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: C&R CARE HOME, LLC
FACILITY NUMBER: 486804299
VISIT DATE: 05/07/2026
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continued from 809....

LPA conducted file review for 4 staff, training found to be up to date.

LPA and admin conducted a spot check of medication. Medication is centrally stored and locked. Two medications not found noted in Centrally Stored Medication Log, LPA had conversation with admin that all medication must be noted in log carefully (Technical Violation given).

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:



LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance
LIC610E Emergency and Disaster plan

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted and report read with Administrator

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

DATE: 05/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/07/2026 01:43 PM - It Cannot Be Edited


Created By: Ethel Contreras On 05/07/2026 at 01:30 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: C&R CARE HOME, LLC
FACILITY NUMBER: 486804299

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and admin record review and observation , the licensee did not comply with the section cited above in two out of four residents Medical assessments are not updated for R1 and R2 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2026
Plan of Correction
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Licensee to submit plan on how Medical Assesments will be updated and once received, copy of medical assesments for S1 and S2 to be sent to CCL by plan of correction due date 5/14/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2026


LIC809 (FAS) - (06/04)
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