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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803289
Report Date: 03/06/2025
Date Signed: 03/06/2025 03:12:30 PM

Document Has Been Signed on 03/06/2025 03:12 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:BEACHWOOD HOUSE, INC.FACILITY NUMBER:
496803289
ADMINISTRATOR/
DIRECTOR:		CABIE, BENJAMINFACILITY TYPE:
735
ADDRESS:1177 BEACHWOOD DRIVETELEPHONE:
(707) 332-9865
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 4CENSUS: 4DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Jhanell Edmalin (House Manager)TIME VISIT/
INSPECTION COMPLETED:
03:21 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Deniz and Cuadra arrived unannounced to conduct an Annual Required Inspection and met with House Manager, Jhanell Edmalin. Facility has a total capacity for 4 residents and an approved fire clearance for 6 ambulatory residents. Annual fees are current. Required postings were observed. Licensee was not able to come to the facility, but was available by phone and LPAs informed the Licensee about deficiencies during the call.

LPAs/staff initiated a tour of the facility at 9:00 am and made the following observations: Facility was a comfortable temperature. LPAs/staff observed that the emergency exit pathway was blocked with rack full of clots and a large dinner table (Citation issued). During the facility walk through LPAs/staff observed in the resident shared room chair and table for the residents (Technical violation issued). Also, LPAs/staff observed garbage bins in the client’s bathroom did not have a cover or lid (technical violation issued). LPAs/staff observed the fence gap on the right side of the backyard needs to repair the small gap and debris all around the backyard needs to be cleaned and organized; House manager had staff removed the debris in the backyard. Toxins are located in a cabinet in the garage that was not locked during inspection and knives were found unlocked in the kitchen (Citation issued). During emergency supply check the facility did not have enough water for all residents for 72 hours (Technical violation issued).

Water temperatures in client bathrooms read at 111.2 and 112.7 which are within regulation of 105 and 120 degrees F. At least two days of perishable and one week of non-perishable food was available. Medication is centrally stored and locked in a cabinet in the kitchen. Fire extinguishers were last inspected on May 6, 2024. Smoke detectors located throughout the facility and the carbon monoxide detector were tested and operational during inspection. Continued on LIC809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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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Document Has Been Signed on 03/06/2025 03:12 PM - It Cannot Be Edited


Created By: Ali Deniz On 03/06/2025 at 01:41 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: BEACHWOOD HOUSE, INC.
FACILITY NUMBER: 496803289

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs/House Manager observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 20 staff (S1 ) was not assosiated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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The licensee agrees to assosiate S1 to the facility on in the Guardian system and submit proof of doing so by POC due date of 03/07/2025
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Ali Deniz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 03/06/2025 03:12 PM - It Cannot Be Edited


Created By: Ali Deniz On 03/06/2025 at 01:41 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: BEACHWOOD HOUSE, INC.
FACILITY NUMBER: 496803289

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs/Staff observation, interview, and record review, the licensee did not comply with the section cited above the fence gap on the right side of the backyard needs a repair, debris all around the backyard needs to be cleaned and organized which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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House manager agrees to remove debris, fix fence, clean and organize backyard. The facility agrees to submit pitcures to clear the citation by plan of correction date.
Type B
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs/Staff observation, interview, and record review, the licensee did not comply with the section cited above the emergency exit pathway was blocked with rack full of clots and a large dinner table which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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House manager removed the one out of two items out of the pathway immediately. The house manager agrees to share the cleared pathway pictures by plan of correction 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.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Ali Deniz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 03/06/2025 03:12 PM - It Cannot Be Edited


Created By: Ali Deniz On 03/06/2025 at 01:41 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: BEACHWOOD HOUSE, INC.
FACILITY NUMBER: 496803289

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs/Staff observation, interview, and record review, the licensee did not comply with the section cited above, the client money/cash resources and found the total money amount and records did not match which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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The licensee agrees to review cash resources to compliance with regulation, facility will submit written plan how they will maintain cash resources logs in compliance by plan of correction date 03/20/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Ali Deniz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


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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: BEACHWOOD HOUSE, INC.
FACILITY NUMBER: 496803289
VISIT DATE: 03/06/2025
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Continued from LIC809C...

LPA initiated file review at 10:00 am. Four client files and three staff files were reviewed. First Aid certificates for staff are current. 1 out of 4 clients did not have medical assessment report on file (Technical violation issued). Licensee followed-up immediately with client's responsible party to obtain the medical assessment. Administrator Certificate for Administrator Benjamin Cabie, 6026669735, expires on 5/30/25. Medications and medication records were reviewed. During the disaster drill records review, facility conducted most recent disaster drill was conducted September 2024, which it is not within compliance of regulation of the facility needs to conduct emergency drills every quarter (Citation issued).

During file review, it was revealed that one staff (S1) was cleared, but they were not associated to the facility, LPA informed Licensee that the staff should never be working and providing care to residents prior to a criminal record clearance or exemption. Civil penalties are being assessed in the amount of $500 for allowing a person to work, reside or volunteer in the facility without a been associated to the facility.



LPAs/staff reviewed cash resources and there were discrepancies found the total money amount and ledgers records did not match (Citation issued). Clients had extra cash amount on hand. According to staff, they have not entered all of the expenses for their logs.

Facility to update the following forms and submit to CCL by 3/20/2025: (LIC308) Designation of Administrative Responsibility, (LIC500) Personnel Report, surety bond, (LIC610E) Emergency Disaster Plan (if any changes).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. ***Civil penalties are being assessed in the amount of $500 for allowing a person to work, reside or volunteer in the facility without a been associated to the facility. Exit interview was conducted with House Manager and copy of this report was given.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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