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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490102164
Report Date: 05/20/2026
Date Signed: 05/20/2026 10:02:03 AM

Document Has Been Signed on 05/20/2026 10:02 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SEBASTOPOL DAY SERVICESFACILITY NUMBER:
490102164
ADMINISTRATOR/
DIRECTOR:		GONZALEZ, SALINAFACILITY TYPE:
775
ADDRESS:167 NORTH HIGH STREETTELEPHONE:
(707) 525-0143
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 30CENSUS: 8DATE:
05/20/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:58 AM
MET WITH:Annette Cutcomb (Site Coordinator)TIME VISIT/
INSPECTION COMPLETED:
10:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management inspection. LPA arrived to the facility and met with Annette Cutcomb, Site Coordinator. The purpose of this case management inspection is to follow up on a self-report incident report submit to Community Care Licensing (CCL).

CCL received a self-reported incident report on 4/15/2026 reporting an incident that occurred on 4/15/2026 about 11:20am involving participant P1, who went AWOL while part of day program group traveled to terrace with staff and site coordinator remained with other members of group in program room. A different senior center class was exiting at the same time, when P1 followed the class as they made their exit from the building, then P1 traveled across two driveways and entered the library next door. Site coordinator alerted staff and the front desk/full staff at the senior center, then called 911. Staff went outside, located P1 at the library, they re-directed P1 back to the program. Site coordinator cancelled the emergency response request and contacted the Program Manager to report the incident. During today’s visit, LPA learned that staff have implement preventive measures: staff will plan to wait for other groups to have cleared passageways prior to moving day program participants. Program Manager will conduct elopement training with all staff. Facilities Polices and Procedure regarding AWOL/Elopement were not followed. LPA reviewed P1’s physician report and needs care plans to confirm that P1 has a diagnosis of dementia. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal Rights Given. Exit interview conducted with site coordinator and copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2026
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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Document Has Been Signed on 05/20/2026 10:02 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 05/20/2026 at 09:37 AM
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: SEBASTOPOL DAY SERVICES
FACILITY NUMBER: 490102164

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2026
Section Cited
CCR
82078(a)

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82078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement. This requirement has not been met as evidence by:
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Administrator agrees to conduct an all staff training to review regulation 82078 regarding care and supervision, submit training date to CCL by 5/21/26 and submit roster of training and topics covered along with attendees to CCL by 6/10/26.
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Based on LPA's interviews, and record review of self-incident report, the facility failed to provide supervision of P1 resulting in P1's AWOL. This poses an immediate health and safety risk.
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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:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2026


LIC809 (FAS) - (06/04)
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