<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801812
Report Date: 06/29/2026
Date Signed: 06/29/2026 03:11:32 PM

Document Has Been Signed on 06/29/2026 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 MANORFACILITY NUMBER:
496801812
ADMINISTRATOR/
DIRECTOR:		ISABEL MELANSONFACILITY TYPE:
740
ADDRESS:9020 SONOMA HWY 12TELEPHONE:
(707) 833-1171
CITY:KENWOODSTATE: CAZIP CODE:
95452
CAPACITY: 16CENSUS: 12DATE:
06/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH:Isabel Melanson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:25 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 Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Isabel Melanson arrived later, Administrator Certificate 7024381740 expires 2/8/27.

At approximately 9:30am LPA toured the building and grounds. Facility currently has twelve (12) residents, two (2) of which are on hospice. LPA observed food stored in a safe manner with all open items covered. However, facility did not have at least a 2 day supply of perishable and 7 day supply of non-perishable food sufficient for 12 residents (deficiency cited, see 809D). Kitchen area is accessible only by half door. Kitchen drawer with sharp knives locked. Laundry room in long hall has cabinet that stores some cleaning solutions and toxins. Additionally, facility has cleaning supplies located in locked closet. Administrator joined LPA on tour of building and grounds after arriving.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperatures in sinks accessible to residents in care measured at 118.3 degrees F in room #11, 110.5 degrees F in room #10, 115.5 degrees F in room #8, 107.3 degrees F in long hall bathroom, 124.2 degrees F in bath next to room #2, and 124.7 in main shower room sink but 104.1 degrees F in main shower room shower head, 147.7 degrees F in room #3 and 149.5 degrees F in room #5. Water temperatures are therefore both over and under the allowable range of 105 to 120 degrees F (deficiency cited, see 809D). Fan switch in main shower room malfunctioning as it will not stay in the on position (deficiency cleared, see 809D).

Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2026
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 7
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)
Page: 2 of 7
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: 06/29/2026
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
26
27
28
29
30
31
32
Continued from 809...

Fire extinguishers were last inspected 12/9/26. Smoke/Carbon Monoxide detectors located throughout the facility are serviced by vendor, last serviced 3/13/26. Fire disaster drill conducted February 2026. Facility has a backup generator for use during a power outage. Facility has a back cottage that was previously utilized as an office and indicated as such on current facility sketch. Back cottage is now utilized as a live-in staff room. Area designated as RV parking/garage on current facility sketch is also being utilized as a live-in staff room in which two (2) staff members sleep and reside (deficiency cited, see 809D). Facility recently changed ownership; new owner is applying for licensure. Applicant present at facility during today's inspection. LPA and applicant discussed ensuring facility sketch is up to date and that no one occupies spaces not designated for living until fire clearance is granted.

At approximately 12:30pm LPA conducted review of five [5] staff records. All required documentation present. Staff S1 and S2 did not have TB clearance on file (deficiency cited, see 809D).

At approximately 1:30pm LPA conducted a review of six [6] resident records. Residents R1, R2, and R3 did not have current physician reports on file (deficiency cited, see 809D).

At approximately 2:30pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in locked room. No deficiencies. LPA, Admin, and applicant discussed ensuring PRN MAR records resident outcomes.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report, LIC308- Designation of Responsibility, and Liability Insurance

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 Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator 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: 06/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/29/2026 03:11 PM - It Cannot Be Edited


Created By: Christi Coppo On 06/29/2026 at 02:42 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: GREEN ACRES MANOR
FACILITY NUMBER: 496801812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that Area designated as RV parking/garage on current facility sketch is also being utilized as a live-in staff room in which two (2) staff members sleep and reside, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
1
2
3
4
Facility to submit updated sketch and LIC 200 to CCL by plan of correction due date. LPA discussed with applicant licensee that no staff shall reside in garage or sleep in garage until fire clearance is granted. Once LIC200 and updated sketch are received CCL will send STD850 to fire department for fire clearance inspeciton.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that water temperatures in sinks accessible to residents in care measured at 118.3 degrees F in room #11, 110.5 degrees F in room #10, 115.5 degrees F in room #8, 107.3 degrees F in long hall bathroom, 124.2 degrees F in bath next to room #2, and 124.7 in main shower room sink but 104.1 degrees F in main shower room shower head, 147.7 degrees F in room #3 and 149.5 degrees F in room #5. Water temperatures are therefore both over and under the allowable range of 105 to 120 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
1
2
3
4
Facility to submit plan to submit 3 day water temperature log showing rooms #3, #5, bath next to room #2 and main shower room sink and shower head are within 105-120 degrees F. 3 day water temperature log due no later than 7/13/26.
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:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 06/29/2026 03:11 PM - It Cannot Be Edited


Created By: Christi Coppo On 06/29/2026 at 02:42 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: GREEN ACRES MANOR
FACILITY NUMBER: 496801812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 LPA and Admin observation, the licensee did not comply with the section cited above in that Fan switch in main shower room malfunctioning as it will not stay in the on position, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
1
2
3
4
Facility to submit to CCL video showing fan switch operational by plan of correction due date.
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
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 06/29/2026 03:11 PM - It Cannot Be Edited


Created By: Christi Coppo On 06/29/2026 at 02:42 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: GREEN ACRES MANOR
FACILITY NUMBER: 496801812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin record review, the licensee did not comply with the section cited above in that S1 and S2 did not have TB clearance on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
1
2
3
4
Facility to submit proof of TB clearance for S1 and S2 by plan of correction due date.

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:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 06/29/2026 03:11 PM - It Cannot Be Edited


Created By: Christi Coppo On 06/29/2026 at 02:42 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: GREEN ACRES MANOR
FACILITY NUMBER: 496801812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that facility did not have at least a 2 day supply of perishable and 7 day supply of non-perishable food sufficient for 12 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
1
2
3
4
Facility to submit 7 day menu for 12 residents, 3 meals for each day. Facility to submit receipts for food that will be used to make/cook menu items identified in 7 day menu by plan of correction due date.
Type B
Section Cited
CCR
87463(h)(1)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin record review, the licensee did not comply with the section cited above in that R1, R2, and R3 did not have current physician reports on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
1
2
3
4
Facility to submit current physician reports for R1, R2, and R3 by plan of correction due date.
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:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2026


LIC809 (FAS) - (06/04)
Page: 7 of 7