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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801588
Report Date: 10/02/2026
Date Signed: 10/02/2026 04:12:44 PM

Document Has Been Signed on 10/02/2026 04:12 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:CHANATE CARE HOMEFACILITY NUMBER:
496801588
ADMINISTRATOR/
DIRECTOR:		CREDO, JOSEPHINEFACILITY TYPE:
740
ADDRESS:3615 CHANATE RD.TELEPHONE:
(707) 526-4153
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 5CENSUS: 5DATE:
10/02/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Maria Caadyang, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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At approximately 2:30 PM Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Non-compliance Inspection and was greeted by Caregiver Maria Caadyang .

On of 6/10/2026 the licensee agreed to be on a Non-Compliance plan for two (2) years. The areas of concern were identified as:
· Medication Management
· Record keeping (Administrator)

During today's inspection LPA audited Medications. LPA observed the following:
-Medications of former residents not in a specific bin or bag marked for destruction.
-Names on medication bottles blacked out with a marker.
These deficiencies will be cited.

LPA attempted to review employee files to check training documents; however, LPA was told that staff files are currently not at the facility. This deficiency will be cited.

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, and Appeal Rights discussed and provided to Caregiver Caadyang. Signature on form confirms receipt of documents.
Victoria Bertozzi
Robert Frank
DATE: 10/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2026
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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Document Has Been Signed on 10/02/2026 04:12 PM - It Cannot Be Edited


Created By: Robert Frank On 10/02/2026 at 03:29 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: CHANATE CARE HOME
FACILITY NUMBER: 496801588

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2026
Section Cited
CCR
87465(i)

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87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services...shall be destroyed in the facility by the facility administrator and one other adult who is not a resident...
This requirement is not met as evidenced by:
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Licensee to provide proof that all medications of former residents have been destroyed in accordance to regulations to Community Care Licensing by POC due date of 10/5/2026. Licensee is also to provide an LIC 9098 Self Certifying that going forward all
medications not being used by
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Based on observation & express admission the licensee did not comply with the section cited above in that medications of former residents were not properly destroyed which poses an immediate health, safety or personal rights risk to persons in care.
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current residents and all medications of former residents shall be properly destroyed.
Type A
10/05/2026
Section Cited
CCR87465(h)(4)

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87465 Incidental Medical and Dental Care (h)The following requirements... medications...centrally stored: (4)All centrally stored medications shall be labeled and maintained...No persons other than the dispensing pharmacist shall alter a prescription label.
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Licensee to provide proof that all staff members assisting residents with medication administration have taken Medication Management training. Medication management training to have taken place in the current year.
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This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that names of residents on prescription medication bottles were crossed out with a black marker which poses an immediate health, safety or personal rights risk to persons in care.
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Proof of training and self certification to be submitted to Community Care Licensing by POC due date of 10/5/2026.
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: 10/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2026 04:12 PM - It Cannot Be Edited


Created By: Robert Frank On 10/02/2026 at 03:50 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: CHANATE CARE HOME
FACILITY NUMBER: 496801588

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2026
Section Cited
CCR
87412(g)

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87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
This requirement is not met as evidenced by:
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Licensee to return all staff files to the facility and to submit an LIC 9098 self certification stating staff files will not be removed from the facility in the future. Self certification to be submitted to Community Care Licensing by POC due date of 10/16/2026.
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Based on observation & express admission, the licensee did not comply with the section cited above in that all staff records have been removed from the facility which poses a potential health, safety or personal rights risk to persons in care.
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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: 10/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2026


LIC809 (FAS) - (06/04)
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