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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804383
Report Date: 07/06/2026
Date Signed: 07/06/2026 04:27:37 PM

Document Has Been Signed on 07/06/2026 04:27 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:AGING IN THE BAY 4FACILITY NUMBER:
486804383
ADMINISTRATOR/
DIRECTOR:		MENDAROS, CHARMAINEFACILITY TYPE:
740
ADDRESS:2290 CORMORANT DRIVETELEPHONE:
(510) 388-7352
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 6DATE:
07/06/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Applicant Charmaine MendarosTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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At approximately 10:00 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a Pre-Licensing inspection for a Change of Ownership (CHOW) and was greeted by two care staff (S1 and S2) neither of which had Guardian Association to Aging in the Bay 4, but do have Association to a sister facility. Licensee was able to work with Community Care Licensing during today's pre-licensing inspection to get the staff members associated to Aging in the Bay 4.

Applicant Charmaine Mendaros was called to advise of today's CHOW inspection who arrived at approximately 10:50 AM to further assist with today's inspection This CHOW is for AWU Home Health LLC.

Facility received a fire clearance on 05/27/2026 to care for 6 (six) residents including 5 non-ambulatory and 1 bedridden resident that can be helped in bedroom #1 only as seen on newest facility sketch. The current facility has a hospice clearance for 4 residents.

Facility is a Residential Care Facility for the Elderly (RCFE) with 6 (six) Residents in care one of which is currently in the hospital; three residents are receiving hospice care.

At approximately 11:15 AM, LPA initiated a tour of the facility with applicant and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to residents. Residents' bedrooms were inspected and observed to have the appropriate furnishings as outlined in Title 22 regulations.

Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2026
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: AGING IN THE BAY 4
FACILITY NUMBER: 486804383
VISIT DATE: 07/06/2026
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Continued from LIC809

A rear bathroom was noted to have two (2) missing baseboard to the left of the toilet and under the sink that will need to be replaced before the new license is issued. In addition, the backyard fence has damaged boards that will need to replaced to ensure resident safety (for example if a small dog moved in next door)

Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a covered seating area in the enclosed front yard with outdoor space for activities. LPA observed locked sheds in the backyard which LPA inspected and observed the contents which consist of tools and extra facility equipment.

LPA observed games, puzzles, and activities for residents in care.

Facility's fire extinguisher was observed charged and was last serviced February 2026. Smoke and Carbon Monoxide detectors were tested and operational during inspection, as well as, no-smoking signs and oxygen in use signs were posted. LPA reviewed facilities Emergency Disaster and Infection Control plans which were last updated 11/11/2025

At approximately 1:45 PM, LPA reviewed four (4) Staff files, two staff members had to be associated in Guardian from a sister facility during today's pre-licensing inspection and another staff member was missing evidence of 1st Aid training. LPA then reviewed six(6) Resident Files and 6 of 6 had required documentation per title 22 regulations.

At approximately 2:00 PM LPA observed facilities Medicine Administration Records (MAR) and both LPA and Licensee observed that five(5) of six (6) Resident MARs were missing evidence of administration of medicines for 07/05/2026.

Applicant states facility and residents' families work together to coordinate medical and dental appointments and residents' family coordinate transportation to and from visits. Facility will not does not manage cash resources for residents.

Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026
LIC809 (FAS) - (06/04)
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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: AGING IN THE BAY 4
FACILITY NUMBER: 486804383
VISIT DATE: 07/06/2026
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Continued from LIC809-C

Component III Orientation was conducted with Applicant Charmaine Mendaros

LPA and Applicant discussed the following items:

· The need for updated Liability Insurance


· Updated Admission Agreements and Care Plans - Applicant understands that they will need to complete new Agreements and Care Plans for all residents once Facility License is approved.
· Guardian background clearances and associations - Applicant understands that all current staff members associated to Aging in the Bay 4 (486804180) will need to be transferred and associated to new facility license (486804383) once approved.

**Facility will need to repair 4 (four) fence boards and two (2) bathroom base boards
In addition facility will need to perform a Plan of Correction for a Type A deficiency by 07/08/2026 BEFORE the new license can be granted.

LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status.

Exit interview conducted. Copy of report discussed and provided with Applicant Charmaine Mendaros. Signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2026 04:27 PM - It Cannot Be Edited


Created By: Star Stevenson On 07/06/2026 at 02:38 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: AGING IN THE BAY 4
FACILITY NUMBER: 486804383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87465(d)(3)

(d) iif the resident is unable to determine his/her own need for prescription or ...PRN mediation...facility staff ...shall be permitted to assist the resident with self-administration, provided all of the following...are met: (3) The date and time the..medication was taken, the dosage taken, and the residents response shall be documented and maintained in the resident's facility record
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above in five (5) out of six (6) residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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LIcensee to provide proof of training for all staff members on General Regulations in 87465 on the concepts of Medicine Administration and tracking by 07/17/2026
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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2026


LIC809 (FAS) - (06/04)
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