486804354-6-10-2026-21-AS-ADEZ-DUWQFR-20260610120821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804354
Report Date: 06/10/2026
Date Signed: 06/10/2026 12:08:36 PM

Document Has Been Signed on 06/10/2026 12:08 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:	AF CARE HOME		FACILITY NUMBER:	486804354
ADMINISTRATOR/ DIRECTOR:	CRUZ, RACHEL BAYLEN		FACILITY TYPE:	740
ADDRESS:	225 WYOMING STREET		TELEPHONE:	(707) 342-4610
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 6		CENSUS: 0	DATE:	06/10/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Rachel Baylen and Flores Baylen, Applicants		TIME VISIT/ INSPECTION COMPLETED:	12:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/10/2026 at approximately 9:30A.M., Licensing Program Analyst (LPA) Ali Deniz conducted a pre-licensing inspection and was greeted by Applicants Rachel Baylen and Flores Baylen. The inspection was conducted as part of the initial licensing process. The facility is a single-story residence consisting of six (6) resident bedrooms, three (3) bathrooms, one (1) staff bedroom, one (1) office, and common living areas. The facility received an approved fire clearance dated 01/15/2026 for a capacity of six (6) residents, including three (3) ambulatory and three (3) non-ambulatory residents. At the time of the visit, there were no residents in care. LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. The facility was found to be clean and comfortable temperature with bedroom doors free from obstruction. Facility has an Infection Control plan on file. LPA observed fire extinguishers mounted on the kitchen and hallway walls. The fire extinguishers were purchased new on 01/08/2026, and proof of purchase was provided and reviewed. Cleaning products, sharp items, other toxins and chemicals are kept in the kitchen cabinets and laundry room were secured and locked. Additional supply of hygiene products available to residents. Water was measured at 113.6-degrees F in faucets used by residents which is within regulation between 105- & 120-degrees F. LPA observed one all bathrooms did have grab-bars and non-slip bathmats. Mattress pads were in place or available for resident’s use. All emergency exits were found to be unobstructed. Facility has combination smoke and carbon monoxide detectors which were operational during visit. LPA observed that the facility is equipped with a fire sprinkler system. Documentation reviewed indicated the system was last inspected on 10/26/2025 and was in working order at the time of the inspection. LPA confirmed that the contents of the facility's First Aid Kit were sufficient. Continued on LIC809-C page...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/10/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

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: AF CARE HOME	FACILITY NUMBER: 486804354
	VISIT DATE: 06/10/2026

NARRATIVE

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Continued from 809 page...
LPA observed emergency lighting throughout the facility. Emergency water supplies were available on-site and readily accessible at the time of the inspection. LPA also observed an adequate supply of nonperishable food in compliance with regulatory requirements. Applicants were advised to obtain and maintain an adequate supply of fresh food prior to accepting residents into care. The facility was equipped with an adequate supply of kitchen utensils and equipment. Applicants stated that sharp objects, including knives, will be stored in a locked location at all times. LPA observed a locked medication cabinet located in the office. Applicants stated that all resident medications will be secured in a locked storage area at all times.

LPA observed the required postings including emergency disaster plan, the Let Us Know Complaint poster and See Something Say Something poster.

RCFE Component III was reviewed with Applicants.

No Deficiencies or Advisories given during visit. Pre-Licensing completed. Facility is ready to be Licensed as a Residential Care Facility for Elderly (RCFE). LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicants of Status.

Exit interview conducted. Copy of report discussed and provided to Applicants. The signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/10/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

LIC809 (FAS) - (06/04)

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