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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800668
Report Date: 08/01/2025
Date Signed: 08/01/2025 12:58:54 PM

Document Has Been Signed on 08/01/2025 12:58 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:SARAH'S ADULT RESIDENTIAL CAREFACILITY NUMBER:
496800668
ADMINISTRATOR/
DIRECTOR:		GREGORI, LINDSEYFACILITY TYPE:
735
ADDRESS:3030 TERRA LINDA DRIVETELEPHONE:
(707) 527-8990
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 3DATE:
08/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Leah Lawrence, Caregiver
Sarah Lawrence, Licensee		TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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At approximately 8:25 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year inspection and was greeted by Caregiver Norma Guzman. Administrator Lindsey Gregori was not present during today's inspection. Staff member Leah Lawrence arrived at 9:30 AM. Licensee Sarah Lawrence arrived at 12:20 PM. Sarah's Adult Residential Care is Licensed as an Adult Residential Facility (ARF). The facility is a single story ranch house. The facility has an approved fire clearance for six (6) ambulatory Clients between the ages of eighteen (18) and fifty-nine (59). Upon arrival, LPA was informed that there were three (3) clients in care and one (1) staff members on-site. LPA reviewed the Facility's Staff Roster and observed that two (2) staff members were not associated to the facility on the Guardian background check system. This deficiency will be cited. A civil penalty of $100 will be issued per staff member for this infraction.

At approximately 8:45 AM, LPA toured the facility. All exits were clear and unobstructed. The facility's one (1) fire extinguisher was last serviced and tagged on 11/5/2024. Food supply was sufficient. The facility was sufficiently lighted. LPA inspected four (4) client bedrooms and observed all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Facility has an infection control plan as required. The facility has a required emergency disaster plan. Per regulation, the facility should be conducting fire and emergency drills quarterly. The last disaster drill was conducted on 8/13/2024. This deficiency will be cited. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. LPA observed that the open kitchen window did not have a window screen. This deficiency will be cited.

Continued on 809-C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2025
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: SARAH'S ADULT RESIDENTIAL CARE
FACILITY NUMBER: 496800668
VISIT DATE: 08/01/2025
NARRATIVE
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...Continued from 809
Hot water temperatures for all sinks in facility were observed to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. During the inspection, LPA observed the medication closet to be unlocked. This deficiency will be cited. LPA further observed toxins to be to be accessible to clients. LPA observed toxins underneath the house, a can of paint in the back yard and cleaning products in the garage to be accessible to clients. Additionally, LPA observed knives and tools to be accessible to clients in the kitchen area. These deficiencies will be cited. LPA observed broken furniture and miscellaneous items in the garage that need to be removed from the facility. This deficiency will be cited.

At approximately 10:30 AM, LPA reviewed two (2) client files. Two (2) client files were observed with all required documentation. The file for client C1 was removed from the facility. Per regulations, the client files should remain at the facility. This deficiency will be cited. LPA was unable to review staff files as they were removed from the facility. Per regulations, the staff files should remain at the facility. This deficiency will be cited.
Lindsey Gregori's Administrator Certification 7004980735 is current with an expiration date of 5/27/2026.LPA requested the following documents be submitted to Community Care Licensing by 9/1/2025:

LIC 500 Personnel Report


LIC 308 Designation of Responsibility
LIC 610D Emergency Disaster Plan
Updated Admissions form

Annual Inspection Continuation Visit to be conducted at a later date.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809Ds, Plan of Corrections, LIC 421BG, LIC 421 FC, 811 Confidential Names and Appeal Rights discussed and provided to Licensee Lawrence. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/01/2025 12:58 PM - It Cannot Be Edited


Created By: Robert Frank On 08/01/2025 at 11:43 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: SARAH'S ADULT RESIDENTIAL CARE
FACILITY NUMBER: 496800668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that Paint and caulking was found under house, a paint can was observed on chair in back yard, cleaning products were observed unsecure in garage and unsecured knives were observed in kitchen drawers. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2025
Plan of Correction
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Licensee will submit LIC 9098 Self certifying that all toxins and knives are being kept inaccessable to clients in care to Community Care Licensing by POC due date of 8/4/2025.
Type A
Section Cited
HSC
1522(c)(1)
General Provisions
(c)(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, residence, or initial presence in the facility. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that staff members S1 and S2 were not associated to the facility in the Guardian background check system which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2025
Plan of Correction
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Licensee will submit LIC 9098 Self certifying that staff members S1 and S2 will not work in the facility until they are associated with the facility on the Guardian Background Check System to Community Care Licensing by POC due date of 8/4/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/01/2025 12:58 PM - It Cannot Be Edited


Created By: Robert Frank On 08/01/2025 at 11:43 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: SARAH'S ADULT RESIDENTIAL CARE
FACILITY NUMBER: 496800668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the medicine storage closet was observed to be unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2025
Plan of Correction
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Licensee will submit LIC 9098 Self certifying that staff have been trained in medication management to Community Care Licensing by POC due date of 8/4/2025.
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/01/2025 12:58 PM - It Cannot Be Edited


Created By: Robert Frank On 08/01/2025 at 11:43 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: SARAH'S ADULT RESIDENTIAL CARE
FACILITY NUMBER: 496800668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2025

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
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Based on observation, the licensee did not comply with the section cited above in that LPA observed broken furniture and miscellaneous items in the garage that need to be removed from the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Licensee to submit pictures showing broken furniture removed from garage to Community Care Licensing by the POC due date of 8/29/2025.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the window directly above the kitchen sink was missing the window screen which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Licensee to submit picture of kitchen window showing a window screen in place to Community Care Licensing by POC due date of 8/29/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/01/2025 12:58 PM - It Cannot Be Edited


Created By: Robert Frank On 08/01/2025 at 11:43 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: SARAH'S ADULT RESIDENTIAL CARE
FACILITY NUMBER: 496800668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interview the licensee did not comply with the section cited above in that all staff files were not at the facility during the inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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3
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Licensee to submit LIC 9098 Self Certifying that all staff records were returned to the facility and will not be removed in the future to Community Care Licensing by POC due date of 8/29/2025.
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

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 that client C1's file was not at the facility during the inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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3
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Licensee to submit LIC 9098 Self Certifying that client C1's file was returned to the facility and will not be removed in the future to Community Care Licensing by POC due date of 8/29/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/01/2025 12:58 PM - It Cannot Be Edited


Created By: Robert Frank On 08/01/2025 at 11:43 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: SARAH'S ADULT RESIDENTIAL CARE
FACILITY NUMBER: 496800668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that quarterly emergency disaster drills are not being held which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Licensee to submit LIC 9098 Self Certifying that Emergency disaster drills wll be held quarterly. Additionally, Licensee will provide a disaster drill log for a drill held in August, 2025 to Community Care Licensing by POC due date of 8/29/2025.
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2025


LIC809 (FAS) - (06/04)
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