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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801117
Report Date: 04/18/2025
Date Signed: 04/18/2025 12:13:19 PM

Document Has Been Signed on 04/18/2025 12:13 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:BIRDIE HOUSEFACILITY NUMBER:
496801117
ADMINISTRATOR/
DIRECTOR:		CHRISTINE WOLTERINGFACILITY TYPE:
740
ADDRESS:1402 BIRDIE DRIVETELEPHONE:
(707) 837-9010
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
04/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Guadalupe Rivera,
Back Up Administrator		TIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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At approximately 8:45 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and was greeted by Caregiver (CG) Isidro Diaz. CG/Back Up Administrator (BUA) Guadalupe Rivera arrived at 9:00 AM. Administrator Christine Woltering was not at the facility, but notified via telephone by the LPA at the time of the inspection. Birdie House is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a multi-story house with residents residing on the first floor only. The facility has an approved fire clearance for six (6) non-ambulatory residents. The facility has a Hospice Waiver for one (1) residents. Upon arrival, LPA was informed that there is one (1) resident in care. At approximately 9:10 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 9:15 AM, LPA toured the facility with CG/BUA Rivera. All exits were clear and unobstructed. The facility's two (2) fire extinguishers were last serviced and tagged in 4/2024. The facility was sufficiently lighted. LPA inspected three (3) resident bedrooms and found 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 residents. Unsecured cleaning products were observed under the kitchen sink. This deficiency will be cited. Facility has an infection control plan as required. The facility has a required emergency disaster plan. Per regulation, Emergency Disaster Drills should be held quarterly. The facility did not have an Emergency Disaster Drill log. LPA was told by CG/BUA Rivera that the last Emergency Disaster Drill was conducted in 12/2024. This deficiency will be cited.

Continued on 809-C...
Victoria BertozziTELEPHONE: (707) 588-5059
Robert FrankTELEPHONE: (707) 588-5026
DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2025
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 5
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: BIRDIE HOUSE
FACILITY NUMBER: 496801117
VISIT DATE: 04/18/2025
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...Continued from 809

The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational.

At approximately 10:00 AM, LPA reviewed one (1) resident files. The resident's files was observed with all required documentation. LPA reviewed two (2) staff files. All staff files were observed with all required documentation including First Aid and CPR certification. One (1) staff member's (S1) file did not have training documentation for 2024. This deficiency will be cited. A Civil Penalty will be assessed for this deficiency as this deficiency has occurred twice in under a year. LPA spot checked Medication for the one (1) resident. LPA observed all medications to be centrally stored, secure and with proper documentation. The facility does not handle resident’s monies for personal and incidental items.

Christine Woltering's Administrator Certification is pending renewal. The application was received on 2/19/2025.
Guadalupe Rivera’s Administrator Certification 7004269740 is current with an expiration date of 4/1/2026.

LPA requested the following documents be submitted to Community Care Licensing by 5/18/2025:


LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Proof of Liability Insurance

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, 811 Confidential Names, LIC 421FC and Appeal Rights discussed and provided to CG/BUA Rivera. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Robert FrankTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/18/2025 12:13 PM - 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: BIRDIE HOUSE
FACILITY NUMBER: 496801117

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 Member S1 did not have annual training documentation in their file for 2024, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2025
Plan of Correction
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Licensee to submit a written plan outlining how they will ensure all staff on site will obtain their annual 20 hour training as required by Health and Safety Code by POC due date of 04/21/2025. Licensee to provide an update on training status to CCL by 05/02/2025 and submit proof of training hours for Staff Member S1 when completed.
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 BertozziTELEPHONE: (707) 588-5059
Robert FrankTELEPHONE: (707) 588-5026

DATE: 04/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2025

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/18/2025 12:13 PM - 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: BIRDIE HOUSE
FACILITY NUMBER: 496801117

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 toxic cleaning solutions were left unsecured under the kitchen sink which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Licensee will submit to Community Care Licensing photographic proof that locks have been added to the cabinet under the kitchen sink or that all cleaning products have been removed by POC due date of 5/02/2025.
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 observation and interview, the licensee did not comply with the section cited above in that Emergency Disaster Drills are not being completed quarterly, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Licensee will submit to Community Care Licensing proof that an Emergency Disaster Drill has been completed by POC due date of 5/02/2025. Licensee will also submit a self certification that Emergency Disaster Drills will be done quarterly in the future by POC due date of 5/02/2025.
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 BertozziTELEPHONE: (707) 588-5059
Robert FrankTELEPHONE: (707) 588-5026

DATE: 04/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2025

LIC809 (FAS) - (06/04)
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