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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803289
Report Date: 03/02/2026
Date Signed: 03/02/2026 03:09:01 PM

Document Has Been Signed on 03/02/2026 03:09 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: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:
03/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Jhanell Edmalin (House Manager)TIME VISIT/
INSPECTION COMPLETED:
03:28 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with House Manager, Jhanell Edmalin. Annual fees are current. Required postings were observed.

LPA/staff initiated a tour the inside and outside of the facility at 11:15 am and made the following observations: Facility was a comfortable temperature, passageway were free from obstructions, client's bedrooms were furnished per regulation with chair, lamp, table and closet. Bathrooms have slip mats, grab bars, garbage cans have a cover lid. Water temperatures in client bathrooms read 112.3 and 112.4 which are within regulation. Toxins are located in a cabinet in the garage and knives were found locked in the kitchen. There was emergency supply and water for all residents for 72 hours. At least two days of perishable and one week of non-perishable food was available. The facility has a generator.

At approximately 11:35am, LPA/staff observed food leftover containers in the refrigerator were not labeled and stored appropriately in order to prevent them from potential contamination.

Medication is centrally stored and locked in a cabinet in the kitchen. Fire extinguishers were last inspected on July, 2025. Smoke detectors located throughout the facility and the carbon monoxide detector were tested and operational during inspection. Disaster drill was conducted on 12/3/25.

LPA initiated file review at 11:45 am. Four client files and three staff files were reviewed. First Aid certificates and training hours for staff are current. Client's weight records were reviewed. Administrator Certificate for Administrator Benjamin Cabie, 7008196735, expires on 5/30/27. Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2026
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BEACHWOOD HOUSE, INC.
FACILITY NUMBER: 496803289
VISIT DATE: 03/02/2026
NARRATIVE
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Continued from LIC809C...

At approximately 12:30pm, LPA/staff observed that the facility is a one story building and has an approved fire clearance dated February 2, 2011 that allows for 4 ambulatory and no non-ambulatory residents and no bedridden resident. However, during records review two clients (C3 & C4) out of four clients have a non-ambulatory status, which are not cleared by the Fire Department for non-ambulatory rooms. Licensee is operating outside the limitation of the license by accepting a non-ambulatory client in an ambulatory room. However, LPA/staff discussed the issue about C3 & C4 to provide the option to submit a request to the Fire Marshall to assess bedrooms to grant fire clearance, but according to the House Manager and LPA observations C3 & C4 are ambulatory. During the visit, LPA observed both clients ambulating without a walker or needing any mobility devices. House Manager will contact C3's & C4's physician to obtain an updated physician's report (LIC602).



At approximately 12:55pm, LPA/staff observed progress notes for client (C4) revealed that back on 10/28/25 at 3:15pm, C4 was seen at the urgent care for bacterial skin infection (cellulitis) of their right lateral lower leg, C4 was under treatment for wound care until 11/12/25, but the facility did not submit incident report to CCL.

At approximately 1:35pm, LPA/staff reviewed cash resources and there were discrepancies found the total money amount and ledgers records did not match. Client (C1) was missing $0.25 cents, client (C2) had extra $0.01 cents, and client (C3) was missing $1. According to staff, they have not entered all of the expenses for their logs accordingly.

At approximately 2:15pm LPA/staff conducted spot check of medication revealed that two out of ten medications Trazadone 100mg tablet and Mirtazepine 15mg tablet for C3 were not logged into the Centrally Stored Medication & Destruction Log accordingly. Per House Manager, they were on vacations and staff on duty forgot to enter the medication into the log once the medication was picked up from the pharmacy.

Facility to update the following forms and submit to CCL by 3/16/2026: (LIC308) Designation of Administrative Responsibility, (LIC500) Personnel Report and surety bond.
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. Exit interview was conducted with House Manager and copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/02/2026 03:09 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/02/2026 at 02:31 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: 03/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 LPA's/House Manager observation, interview and record review, the licensee did not comply with the section cited above in two out of four clients (C3 & C4) have a non-ambulatory status in their physician report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/16/2026
Plan of Correction
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Licensee needs to submit to both of the clients' (C3 & C4) physician to get updated ambulatory status corrected on their LIC602s. The facility will submit self-certification as proof that both items were corrected to CCL by POC due date.
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 LPA's/House Manager observation, interview and record review, the licensee did not comply with the section cited above in three out of four clients' (C1, C2 & C3) money/cash resources, the total money amount and records did not match their ledgers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/16/2026
Plan of Correction
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The Licensee will review cash resources to ensure compliance with regulation, facility will submit written plan how they will maintain cash resources logs in compliance by plan of correction date 03/16/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/02/2026 03:09 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/02/2026 at 02:31 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: 03/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(18)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observation and interview, the licensee did not comply with the section cited above by having food leftovers in the refrigerator not being stored appropriately in order to prevent them from potential contamination, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/16/2026
Plan of Correction
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Licensee to hold an in-service training with staff regarding facility’s storage of food. Submit plan of correction in how the facility will ensure that propper food storage is done by all staff when handling all food in the facility. Submit proof of training by POC due date 3/16/26. Proof of training to, include trainer, topics, date, time spent, attendees, and employee signatures.
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/House Manager observation, interview and record review, the licensee did not comply with the section cited above in two out of ten medications for client C3 were not documented into the CSMDL, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/16/2026
Plan of Correction
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Licensee will review all medications to ensure meds have been documented on the CSMR and will conduct in-service staff on this regulation and submit proof of training to CCL by POC date 3/16/26. Proof of training to, include trainer, topics, date, time spent, attendees, and employee signatures.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 03/02/2026 03:09 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/02/2026 at 02:47 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: 03/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80061(b)(1)(D)
80061 Reporting Requirements (b) Upon the occurrence of event...shall be submitted to the licensing agency within 7 days following the occurrence of such event. (1) Events reported shall include the following: (D) Any injury to any client which requires medical treatment. This requirement has not been met as evidence by...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/House Manager observation, interview and record review, the licensee did not comply with the section cited above by not submitting incident report notifying the Department of C3's wound treatment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/16/2026
Plan of Correction
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Licensee to submit a statement to CCL acknowledging the facility's responsibility to notify designated agencies including NBRC and CCL regarding any change of condition of clients in care and submit the written statement to CCL by POC 3/16/2026.
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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2026


LIC809 (FAS) - (06/04)
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