496801205-2-27-2025-21-AS-ADEZ-DEAUZK-20250227150141

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801205
Report Date: 02/27/2025
Date Signed: 02/27/2025 03:02:06 PM

Document Has Been Signed on 02/27/2025 03:02 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:	HOEN'S CARE HOME		FACILITY NUMBER:	496801205
ADMINISTRATOR/ DIRECTOR:	ALCONES, LILY O.		FACILITY TYPE:	740
ADDRESS:	1618 MARIPOSA DRIVE		TELEPHONE:	(707) 573-8922
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	02/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Licensee Arthur Alconies		TIME VISIT/ INSPECTION COMPLETED:	03:15 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 Analysts (LPAs) Deniz and Cuadra arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Licensee Arthur Alcones arrived later. Facility currently has resident on hospice which is allowable per the facility's Hospice Waiver. LPAs/ Licensee initiated a tour of the facility around 11:45 AM and made the following observations: Facility was a comfortable temperature, and passageways were free from obstructions. LPAs/Licensee observed fences next to the shaded area in the backyard needs to be repaired. Licensee agrees to repairs the damaged fences. LPAs observed emergency exit pathway concrete floor had cracks about 2 inches wide which poses a tripping hazard (Deficiency Citation Issued). Common area bathroom sink’s hose and hot water pressure need to be fixed. Licensee immediately called repair staff and they arrived at the facility for repair while LPAs were in the facility (Deficiency Citation Issued). Resident rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 118 degrees F and 114.2 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water is stored in the storage room per Title 22 regulations. LPAs observed garbage bin was stored next to the clean utensils in the kitchen cabinet located under the kitchen sink. Licensee immediately removed the garbage bin into different space and put new one (technical violation issued). Continue on LIC809C...

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Ali Deniz	TELEPHONE: (707) 588-5087
	DATE: 02/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

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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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: HOEN'S CARE HOME	FACILITY NUMBER: 496801205
	VISIT DATE: 02/27/2025

NARRATIVE

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Continue from LIC809...

Fire extinguishers were last serviced February 13, 2025. Facility smoke detectors located throughout the facility were tested and operational during inspection. But carbon monoxide detector wasn’t functional, and Licensee replaced it (Technical violation issued). Most recent fire/disaster drill was conducted 02/13/2025.

LPAs initiated file review at 1:00pm. Four staff files and four resident files were reviewed. Staff have required First Aid and CPR certificates. Medications and medication records were reviewed. Administrator Certificate for Administrator, Lily Alcones # 7003673740 expires 03/10/2026.

LPA is requesting the following documents to be submitted to Community Care Licensing by 03/26/2025:

LIC 500 Personnel Report
LIC 308 Designation of facility responsibility
Updated Liability Insurance
Emergency Disaster Plan (Review and update if need it)

Control of property.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted. Copy of report discussed and provided to Licensee.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Ali Deniz	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/27/2025 03:02 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: HOEN'S CARE HOME	FACILITY NUMBER: 496801205
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs/Licensee observation and interview, the licensee did not comply with the section cited above in LPAs observed fences next to the shaded area in the backyard needs to be repaired; Common area bathroom sink hose and hot water pressure need to be fixed, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/13/2025
	Plan of Correction
1 2 3 4	Licensee agrees to perform repairs to items of concern and will submit pictures as proof of correction to CCL by POC due date 3/13/25.

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	TELEPHONE: (707) 588-5059
Ali Deniz	TELEPHONE: (707) 588-5087
	DATE: 02/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

LIC809 (FAS) - (06/04)

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