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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801684
Report Date: 03/11/2025
Date Signed: 03/11/2025 02:47:23 PM

Document Has Been Signed on 03/11/2025 02:47 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AA BEST CARE HOMESFACILITY NUMBER:
496801684
ADMINISTRATOR/
DIRECTOR:
AQUINO, NICANORFACILITY TYPE:
740
ADDRESS:857 HEARN AVE.TELEPHONE:
(707) 546-8413
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 40CENSUS: 24DATE:
03/11/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Charito Santos (Administrative Assistant)TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Cuadra and Contreras conducted an unannounced subsequent case management and met with Administrative Assistant Charito Santos. The purpose of this subsequent case management visit is to continue the follow up on a death certificate to Community Care Licensing (CCL) dated 2/3/25. Previously on 2/4/25 LPA have requested Death Certificate due to resident was not receiving hospice services when they unexpectedly passed away on 2/1/25.

During today's visit LPA conducted interviews with additional residents in care and requested additional documentation regarding R1's health condition prior to their hospitalization on 1/31/25. According to SIR dated 2/3/25; On 1/31/25, R1 was taken by ambulance to the hospital after R1 was unable to walk or put pressure on their leg. Facility staff (S1) noticed that R1 had a wound on their ankle. R1 was transported from the facility to the hospital where they passed away on 2/1/25. Based on records review, R1's physician report dated 6/25/24 did not have a history of any skin condition or breakdown, they had the capacity to perform self-care of activities of daily living including showers, dress, grooming and toileting needs. On 2/4/25, LPA Coppo previously obtained pertinent documentation and interviewed staff. R1's progress notes for the months of August 2024 to January 2025 indicates other health condition unrelated to the wound on their ankle either.

No deficiencies cited during today's visit. The Department will review information obtained to determine if further actions are needed.

Exit interview conducted with Administrative Assistant and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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