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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804323
Report Date: 08/04/2026
Date Signed: 08/04/2026 05:24:51 PM

Document Has Been Signed on 08/04/2026 05:24 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:CARELAND RESIDENTIAL LLCFACILITY NUMBER:
486804323
ADMINISTRATOR/
DIRECTOR:		RUIZ, CLERRFACILITY TYPE:
740
ADDRESS:512 LARAMIE WAYTELEPHONE:
(707) 654-0049
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 5DATE:
08/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Clerr Ruiz-Administrator TIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection and was greeted by administrator Clerr Ruiz. Facility is a Residential Care Facility for the Elderly that has a fire clearance approved for six residents. Facility currently has 5 residents residing.

Upon arrival, LPA checked Guardian Roster and observed all three staff present in facility were not associated to facility roster. S3,S4 and S5 had fingerprint clearance but no association to roster (Deficiency cited, see 809D) An Immediate Civil Penalty in the total amount of $100 was assessed today for non-associated individuals S3, S4 and S5 providing care in this licensed facility.

LPA and staff toured the building and grounds which was found to be clean and in good repair. Facility was clean and at a comfortable temperature. LPA observed all walkways and exits to be unobstructed. All required postings were in a highly visible area. During walk through, LPA observed drawer in bathroom accessible to residents to have an unsecured drawer with medications including vitamins, ibuprofen, and nasal spray. In addition, LPA observed unsecured medication in unlocked kitchen cabinet (Deficiency Cited, see 809D). Resident bathroom had required bath mat and grab bar. Water temperature measured at faucets accessible to residents is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were charged and last inspected 3/31/2026. Disaster drills are conducted. Fire alarms and carbon monoxide detector were tested and operational. Outdoor emergency exit clear from obstruction. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable foods. Facility kitchen, refrigerators and freezers were clean, food in leftover plastic containers did not have expiration dates noted (Technical Violation given). Sharps and knives were locked in kitchen drawer. Emergency water and food supply observed.

continued onto 809C...
Kimberley Mota
Ethel Contreras
DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2026
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: CARELAND RESIDENTIAL LLC
FACILITY NUMBER: 486804323
VISIT DATE: 08/04/2026
NARRATIVE
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continued from 809.....

Facility had an ample supply of linens, towels and extra hygiene products for residents. All bedrooms were equipped with lighting, a night stand and chest of drawers. All bedrooms were clean and in good repair.

LPA reviewed 5 resident records. R1, R2,R3 and R5 were missing Medical Assessment and TB Clearance(Deficiency Cited, See 809D).
R1,R2, were missing Needs and Service Plans, Reappraisal. R4 was missing all required paperwork(Deficiency Cited, See 809D).

LPA reviewed 3 staff records. Staff S1,S2 and S3 lacked required 20 hours annual training (Deficiency Cited, see 809D). No Personnel Records present at facility available for LPA to review including LIC503 Health Screening and LIC501 Personnel Record for all staff (Deficiency Cited, see 809D).

LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies

Administrator will be referred to TSP Services.



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

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: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 08/04/2026 05:24 PM - It Cannot Be Edited


Created By: Ethel Contreras On 08/04/2026 at 04:19 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: CARELAND RESIDENTIAL LLC
FACILITY NUMBER: 486804323

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Licensee observation, the licensee did not comply with the section cited above in S3,S4,S5 are not associated to facility Guardian Roster which poses an immediate health, safety or personal rights risk to persons in care
POC Due Date: 08/05/2026
Plan of Correction
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Licensee to associate all staff to Guardian Roster and submit to CCL facility Guardian roster print out showing all staff as being associated to the facility by Plan of Correction due date 8/05/2026.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Licensee observation the licensee did not comply with the section cited above in LPA observed drawer in bathroom accessible to residents to have an unsecured drawer with medications including vitamins,ibuprofen, and nasal spray. In addition, LPA observed unsecured medication in unlocked kitchen cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2026
Plan of Correction
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Licensee to submit LIC9098 with proof of picture that all medication has been locked and stored properly by plan of correction due date 8/04/2026.
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: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2026 05:24 PM - It Cannot Be Edited


Created By: Ethel Contreras On 08/04/2026 at 04:19 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: CARELAND RESIDENTIAL LLC
FACILITY NUMBER: 486804323

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and licensee obervation the licensee did not comply with the section cited above in that Personnel Records were not present at facility available for LPA to review including LIC503 Health Screening and LIC501 Personnel Record for all staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2026
Plan of Correction
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Licensee to submit LIC503 and LIC501 for all staff to CCLD by plan of correction due date 8/11/2026.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Licensee review and observation the licensee did not comply with the section cited above in Staff S1,S2 and S3 lacked required 20 hours annual training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2026
Plan of Correction
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Licensee to submit proof that staff have been signed up or in process of required 20 hour required training to CCL by plan of correction due date 8/11/2026
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: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/04/2026 05:24 PM - It Cannot Be Edited


Created By: Ethel Contreras On 08/04/2026 at 04:19 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: CARELAND RESIDENTIAL LLC
FACILITY NUMBER: 486804323

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA and Licensee observation and record review the licensee did not comply with the section cited above in R1,R2, were missing Needs and Service Plans, Reappraisal. R5 was missing all required paperwork

which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2026
Plan of Correction
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Licensee to submit all required missing paperwork for R1,R2 and R5 to CCL by Plan of Correction due date 8/11/2026
Type B
Section Cited
CCR
87458(c)(1)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on LPA and Licensee observation and record review , the licensee did not comply with the section cited above in R1, R2,R3 and R5 were missing Medical Assessment and TB Clearance which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2026
Plan of Correction
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3
4
Licensee to submit Heath Screening and Tb results to CCL by Plan of Correction Due date 8/11/2026.
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: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2026


LIC809 (FAS) - (06/04)
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