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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490104577
Report Date: 03/20/2026
Date Signed: 03/20/2026 01:15:41 PM

Document Has Been Signed on 03/20/2026 01:15 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:SENIOR DAY PROGRAMFACILITY NUMBER:
490104577
ADMINISTRATOR/
DIRECTOR:		CIMINO, MONTEFACILITY TYPE:
775
ADDRESS:25 HOWARD STREETTELEPHONE:
(707) 765-8490
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY: 20CENSUS: 18DATE:
03/20/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Program Coordinator TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required annual visit and met with Program Coordinator (S1). The program currently operates on Monday, Wednesday, and Friday from 10:00am to 2:00pm. There are currently 18 participants enrolled in the program, 11 of which were present at the time of the visit. Also present at the facility were staff (S2 and S4). Director of Senior Services (DSS), Carolyn Buck was available by phone and arrived later.

LPA arrived at the facility at 9:30am, LPA knocked many times and called the program number but did not receive any answer or call back. S1 opened the door at approximately 9:55am and explained to LPA that they heard knocking but did not answer as they thought LPA was an early participant. LPA asked that in the future if someone could look out the window or answer the door briefly to see who is knocking, as CCL will always arrive unannounced and slightly before program begins so as to give staff time to assist CCL before participants arrive. Additionally, LPA was advised that the DSS has changed from Monti Cimino to Carolyn Buck and the Executive Director (ED) is now Jenifer Weiss. DSS will send to CCL LIC215, LIC500, LIC308, LIC501, detailed employment/education history, and board resolution to change Administrators or what the program calls DSS.

LPA toured the facility at 10:30am which was found to be clean, in good repair, and a comfortable temperature. Program has a kitchen, main activity space, two [2] offices, two [2] bathrooms, and a dining area. LPA observed participants engaged in activity with the program coordinator enjoying music and interactive games.

Water temperatures measured at 112 degrees F in the kitchen, and 106.7 degrees F in the bathroom both of which are within the allowable range of 105 to 120 degrees F. LPA tested smoke/carbon monoxide detector and found it operational. First Aid kit present.

Continued on 809C....
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2026
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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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: SENIOR DAY PROGRAM
FACILITY NUMBER: 490104577
VISIT DATE: 03/20/2026
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Continued from 809...

Lunches are provided by Meals on Wheels. Toxins and cleaning supplies inaccessible to participants. Program does not handle client medications, cash, and there are not any participants requiring oxygen use. Program has a service through Petaluma People's Services called iRide which provides drop off and pick up services for those participants in need of transportation. No hazards were observed in the indoor activity areas and LPA observed fire exits to be unobstructed.

At approximately 10:45am LPA reviewed seven [7] participants files and five [5] staff records. S1, S4, S5, and DSS did not have a health screen on file but did have proof of TB clearance. DSS will send health screens for S1, S4, S5, and DSS to CCL by no later than 4/10/26. LPA advised DSS that staff also need to have an LIC501 (job application) on file.

LPA discussed fire clearance with DSS. The most recent fire clearance was granted in 1994 with clearance for a capacity of fifteen [15]; however, program is licensed for a capacity of twenty [20]. DSS will submit a new LIC200 indicating requested capacity of 20 to CCL. LPA will request fire clearance and send STD850. LPA will follow up with DSS to advise if fire clearance was granted or denied.

Additionally, LPA review of Guardian roster shows S6 and S7's fingerprint clearance as "In Process." Per S1, S6 and S7 are not present at the facility and thus far have only worked at the Petaluma People Services office. LPA advised S6 and S7 may not be present at the facility until fingerprint clearance is showing as Eligible.

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

No deficiencies cited. Exit interview conducted with DSS and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026
LIC809 (FAS) - (06/04)
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