496801812-8-12-2025-21-AS-CCOO-DKGTZQ-20250812151043

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801812
Report Date: 08/12/2025
Date Signed: 08/12/2025 03:11:03 PM

Document Has Been Signed on 08/12/2025 03:11 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:	GREEN ACRES MANOR		FACILITY NUMBER:	496801812
ADMINISTRATOR/ DIRECTOR:	ISABEL MELANSON		FACILITY TYPE:	740
ADDRESS:	9020 SONOMA HWY 12		TELEPHONE:	(707) 833-1171
CITY:	KENWOOD	STATE: CA	ZIP CODE:	95452
CAPACITY: 16		CENSUS: 12	DATE:	08/12/2025
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:55 PM
MET WITH:	Isabel Melanson, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:20 PM

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Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct a Case Management. LPA met with Administrator (Admin) Isabel Melanson.

On Wednesday 7/30/25 Admin provided LPA detailed updates outlining the current status of plans of corrections issued for deficiencies identified 7/10/25 at Annual Inspection, all plans of corrections were due 7/31/25.

Administrator advised LPA pertaining to:

Deficiency 87303(a) Our range/stove has been repaired. The hinges were replaced on the oven door and it now seals correctly. The ignitors and wiring connected to the ignitors were replaced on both the burners requiring repairs and both burners and now fully functional.

Today, LPA tested range stove during visit and found it to be operational and functioning. LPA observed oven door to close properly. Also, portion of carpet in long main hall that was a potential tripping hazard has been removed and replaced with wood-like flooring. Flooring does not appear to present as a tripping hazard.

Administrator advised LPA pertaining to: Deficiency 87303(e)(2). Plumbing vendor came out to address our water temperature issues. They found that there had been a timer set that had been controlling the output of

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NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025

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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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: GREEN ACRES MANOR	FACILITY NUMBER: 496801812
	VISIT DATE: 08/12/2025

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hot and cold water flow throughout the house. The plumber turned off the timer and that seemed to correct the issue. Water temps seem to be staying in the required levels following the timer being turned off. The plumber said he did not find anything "wrong" or "broken" with any of the 4 water heaters. He did recommend replacing our main water heater with a commercial sized one due to the amount of use our hot water gets.

Today, LPA tested water, water measured at 148.3 degrees F in long hall main bathroom, LPA measured temperature of water coming out of the shower head in the same bathroom and water measured at 100.8 degrees F. Additionally, water measured at 90.8 in jack and jill style bathroom for rooms #9/10, at 118.4 degrees F in long hall bath, and 123.6 degrees F in room #2. LPA and Admin discussed water temperatures. Admin will work with licensee to get water temperature within regulation. Admin agreed to post caution signs above facility sinks accessible to residents indicating that water may be hotter than 125 degrees F. Facility will either repair or replace water heater(s); Admin will advise LPA of plan to replace or repair after discussing with licensee. LPA will return once repairs/replacement is complete to test water.

Administrator advised LPA pertaining to: Deficiency 87555(b)(20). We have ordered a vent for the kitchen as well as scheduled the installation for the vent for Wednesday August 6^th at 8AM.

Today, LPA observed presence of kitchen vent. Vent is operational and functioning.

Administrator advised LPA pertaining to: Deficiency 87309(a). Our handyman was able to repair the cabinet in the laundry room so that the door locks correctly. He will also be repairing our carpet in the long hall way

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NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025

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: GREEN ACRES MANOR	FACILITY NUMBER: 496801812
	VISIT DATE: 08/12/2025

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tomorrow. Once that is completed, I will forward the invoice to you as well as some pics of the repaired carpet.

Today, LPA inspected laundry room cabinet and found its locking feature to be operational and functioning.

LPA confirms that all plans of correction have been satisfied, except 87303(e)(2) for the water temperature. Upon LPA return to SRRO, deficiency clearance letters will be issued to facility. LPA will return at later date to test the water temperature(s).

No deficiencies cited. Exit interview conducted with Admin and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025

LIC809 (FAS) - (06/04)

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