496800621-4-23-2026-21-AS-DALO-DTEURQ-20260423154906

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800621
Report Date: 04/23/2026
Date Signed: 04/23/2026 03:49:26 PM

Document Has Been Signed on 04/23/2026 03:49 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:	WIMBLEDON HOUSE #1		FACILITY NUMBER:	496800621
ADMINISTRATOR/ DIRECTOR:	BARONI, PIA E.		FACILITY TYPE:	735
ADDRESS:	629 WEST 3RD STREET		TELEPHONE:	(707) 527-7628
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95401
CAPACITY: 5		CENSUS: 4	DATE:	04/23/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Ashlyn Poplin-Lead Staff		TIME VISIT/ INSPECTION COMPLETED:	04:00 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	Licensing Program Analyst (LPA) Alviso conducted Required- 1 Year inspection, on 4/23/2026 at approximately 9:40am, and met with Lead staff Ashlyn Poplin. Licensee/Administrator Pia Baroni was not available due to being out of town. Ashlyn is planning to take the administrator exam soon, and an assistant staff to Licensee, as well as a caregiver. Facility has a fire clearance for five (5) ambulatory adults. Facility has a required infection control plan. Facility has a required emergency disaster plan. Fire extinguishers, xxx, were serviced and tagged as required. All exits were free and clear of obstructions. LPA reviewed four (4) resident files. Files were complete. LPA reviewed five (5) staff files. All staff have criminal record clearance as required. Staff had required first aid certification and CPR certification. Staff have annual training, per file reviews. LPA toured the facility with Ashlyn, Lead staff. Hot water was measured at 112. degrees Fahrenheit. There was a sufficient supply of food.There was a sufficient supply of cleaners/disinfectants, soaps, hygiene items, paper products, linens, and furnishings for resident use. The house was at a comfortable temperature. Facility had a supply of emergency food and water as required. All medications were locked up and inaccessible to residents in care. All cleaners/disinfectants were locked up and inaccessible to residents in care. Continued on LIC809C..

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

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: WIMBLEDON HOUSE #1	FACILITY NUMBER: 496800621
	VISIT DATE: 04/23/2026

NARRATIVE

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The LPA is requesting the following forms to completed and submitted by 5/23/26:
LIC 500-Personnel Report
LIC 308-Designation of Responsibility (if changes)
LIC 9020-Register of Facility Client’s
LIC 400 - Affidavit Regarding Client Cash Resources-all facilities need to complete this form
Copy of Surety Bond
Emergency Disaster Plan (if changes submit the plan/ no changes submit copy of the last page signed/dated
Infection Control Plan (if changes submit the plan/ no changes submit copy of the last page signed/dated
Copy of current Administrator Certificate

The following deficiency was observed and will be cited:
LPA toured the facility with staff/S1 and observed that the large living room had a door that had the frame removed from it, and a dresser with a broken drawer. R1's room was very dirty, with garbage, dirt, and dust everywhere around the floor Closet floor was dirty and had garbage and dust everywhere on the floor. R2's room and the closet smelled strongly of urine- crumbs and dirt on dressers. Garbage, dirt, and dust all over the floor and under the bed. LPA discussed with staff S1 the responsibility of ensuring the facility is clean, sanitary, and in good repair at all times, as required by regulations. LPA discussed how the home sits on a large property and they want to help ensure the facility doesn't get rodents from not keeping facility rooms clean and sanitary. S1 stated their understanding of the above and discussed plan of correction and maintenance of facility rooms being clean and sanitary. This deficiency will be cited, 80087(a) Buildings and Grounds- The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors, see LIC809D.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation.

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 Lead staff, Ashlyn Poplin. Report provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/23/2026 03:49 PM - It Cannot Be Edited

Created By: Dina Alviso On 04/23/2026 at 03:26 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: WIMBLEDON HOUSE #1	FACILITY NUMBER: 496800621
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA toured the facility with staff/S1 and observed that the large living room had a door that had the frame removed from it, and a dresser with a broken drawer. R1's room was very dirty, with garbage, dirt, and dust everywhere around the floor Closet floor was dirty and had garbage and dust everywhere on the floor. R2's room and the closet smelled strongly of urine- crumbs and dirt on dressers. Garbage, dirt, and dust all over the floor and under the bed. LPA discussed with staff S1 the responsibility of ensuring the facility is clean, sanitary, and in good repair at all times, as required by regulations. LPA discussed how the home sits on a large property and they want to help ensure the facility doesn't get rodents from not keeping facility rooms clean and sanitary, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2026
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure rooms/facility is cleaned, and is sanitary as required by regulation. Ensure the frame around the door in the large living room is put back on. Facility to ensure a maintenance plan of keeping facility rooms clean and sanitary is in place to ensure future compliance. Please submit plan of correction, including maintenance plan and pictures of corrected items. POC due 5/4/26.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

	Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

LIC809 (FAS) - (06/04)

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