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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801091
Report Date: 04/21/2025
Date Signed: 04/21/2025 11:32:44 AM

Document Has Been Signed on 04/21/2025 11:32 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:HANNA HOUSE SCENICFACILITY NUMBER:
496801091
ADMINISTRATOR/
DIRECTOR:		ADALBERTO OJEDA-MENDEZFACILITY TYPE:
740
ADDRESS:819 SCENICTELEPHONE:
(707) 586-3536
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
04/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:34 AM
MET WITH:Adalberto Ojeda-Mendez (Administrator)TIME VISIT/
INSPECTION COMPLETED:
11:47 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Administrator Adalberto Ojeda and Licensee David Hanna arrived later. Annual fees are current. Required postings were observed. There are residents with dementia diagnosis.

LPA/Administrator initiated a tour of the facility at 8:45 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathrooms measured at 105.6, 107 and 127 degrees F which are not within allowable range of 105 to 120 degrees F (technical violation issued). Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cabinet located in the locked garage and under the sink at the kitchen containing cleaning supplies was locked. Medications were centrally stored and locked.

At approximate 9:00am LPA/Administrator observed that the facility has at least two days of perishable, and has one week of non-perishable foods. LPA/Licensee had a conversation about the importance of having adequate supply of fruit for residents available (technical violation issued). Per Administrator, today is the grocery day for them to buy supply for the week. Facility has emergency food to operate for more than 72 hours during an emergency.
Continues on LIC809C...
Bethany MoellersTELEPHONE: (707) 588-5040
Marisol CuadraTELEPHONE: (707) 588-5078
DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HANNA HOUSE SCENIC
FACILITY NUMBER: 496801091
VISIT DATE: 04/21/2025
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Continued from LIC809...

Fire extinguisher was last inspected July, 2024. Smoke detectors located throughout the facility were tested and operational. Carbon monoxide detector was tested and operational. Exit doors have auditory alert system that were functional at time of visit.

At approximate 10:30am records review indicated that the last disaster drill was conducted on November 2024, but no documentation was on file.

LPA initiated file review at 9:15 am. Three staff files and five resident files were reviewed. One out of five resident's (R1) care plan needs to be updated (technical violation issued). Staff have required First Aid and CPR certificates and completed annual required training hours. Administrator Certificate for Administrator Adalberto Ojeda, 7010339740, expires on 5/10/26.

At approximate 11:00 am a spot check of medication revealed that one out of three residents (R2) medication expiration and start dates were not documented into the CSMDR, but expiration dates were accurate on containers of medications.

Licensee/Administrator agreed to submit updates of the following documents by 4/28/25: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E if there are any changes) and a copy of liability insurance.

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.

Exit interview conducted with Licensee and a copy of this report was given.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/21/2025 11:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: HANNA HOUSE SCENIC
FACILITY NUMBER: 496801091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in one out of three resident's medication expiration and start dates were not documented in the CSMDR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2025
Plan of Correction
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Licensee agrees to review all resident's medication records and will submit a self-certification form LIC9098 to confirm compliance with regulation to CCL by POC due date.
Type B
Section Cited
HSC
1569.695(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above by not conducting a quarterlyt disaster drill which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2025
Plan of Correction
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Licensee agrees to conduct a disaster drill for each shift and will submit a self-certification form LIC9098 to confirm compliance with regulation to CCL by POC due date.
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 MoellersTELEPHONE: (707) 588-5040
Marisol CuadraTELEPHONE: (707) 588-5078

DATE: 04/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2025

LIC809 (FAS) - (06/04)
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