496803311-5-19-2026-21-AS-DALO-DU93HY-20260519181644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803311
Report Date: 05/19/2026
Date Signed: 05/19/2026 06:17:01 PM

Document Has Been Signed on 05/19/2026 06:17 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:	PLATINUM RESIDENTIAL CARE HOME		FACILITY NUMBER:	496803311
ADMINISTRATOR/ DIRECTOR:	SHAUGHNESSEY, MERA		FACILITY TYPE:	740
ADDRESS:	1972 DENNIS LANE		TELEPHONE:	7077578607
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 6		CENSUS: 6	DATE:	05/19/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:00 PM
MET WITH:	Lorena Madriga-Back-up Administrator		TIME VISIT/ INSPECTION COMPLETED:	06:30 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) Alviso conducted a Required- 1 Year visit, on 05/19/26 at approximately 3:00pm, and met with Lorena Madriga-Back-up Administrator. Administrator Mera Shaughnessey arrived to meet with the LPA. There currently are six (6) residents in care. LPA observed two caregivers on duty. Facility has an approved dementia plan of operation. There is an approved hospice waiver for three (3) residents. Facility has a required infection control plan. Facility has an emergency and disaster plan as required. Facility does have a generator for emergencies if needed. The facility does have emergency food, water, and supplies to meet the "72 hour shelter in place" requirements. Emergency disaster drills are being conducted as required. Last emergency disaster drill. was conducted on 4/5/26, wild fire drill, and the previous one was conducted on 1/10/26, power outage drill. LPA reviewed six (6) resident files. All medication records were complete and medications were stored and locked up as required. LPA reviewed five (5) staff files. Staff reviewed all had current required first aid certification and CPR certification. All staff had required criminal record clearance. LPA reviewed staff annual training, and medication training for those staff that assist residents' with medications. The LPA toured the home with the Administrator Mera Shaughnessey. The exits were all free and clear of obstructions. The fire extinguishers were serviced and tagged as required. All medications were locked up and inaccessible to residents in care. All cleaners/disinfectants were locked up and inaccessible to residents in care. Continued on LIC809C..

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

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 4

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 4

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: PLATINUM RESIDENTIAL CARE HOME	FACILITY NUMBER: 496803311
	VISIT DATE: 05/19/2026

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

The facility had a sufficient supply of food. Sufficient supply of hygiene products, linens, soaps/cleaners/disinfectants, furnishings, paper products, and personal protective equipment (PPE) supplies. All bathrooms had non-slip mats/non-slip flooring for resident use. All bathrooms had grab bars for residents use. All common areas, resident rooms, hallways, and bathrooms had sufficient lighting for resident's use. Hot water was measured at 109.6 degrees Fahrenheit.

LPA is requesting the following documents be updated and submitted to CCL by 6/19/26:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610 (9 page)- Emergency Disaster Plan- update if needed- submit copy
Copy of Current Liability Insurance
Copy of Infection Control Plan- update if needed- submit copy
LIC400- Affidavit of Client Cash Resources
Copy of Bond if handling cash, per LIC400

LPA observed the following deficiencies:
During the facility tour, the LPA observed the laundry room door ajar, this is where all cleaners, soaps, and disinfectants are stored. The door has a keypad lock which locks the door when fully closing it.The laundry room was unattended by the staff while unlocked. This deficiency will be cited, 87309(a)(1) Storage Space and Access- Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements, see LIC9099D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation.
Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Licensee/Administrator Mera Shaughnessey.
Appeal Rights provided to the Licensee/Administrator.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/19/2026 06:17 PM - It Cannot Be Edited

Created By: Dina Alviso On 05/19/2026 at 06:04 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: PLATINUM RESIDENTIAL CARE HOME	FACILITY NUMBER: 496803311
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed the laundry room door ajar, this is where all cleaners, soaps, and disinfectants are stored. The door has a keypad lock which locks the door when fully closing it.The laundry room was unattended by the staff while unlocked, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/20/2026
	Plan of Correction
1 2 3 4	Licensee/Administrator to hold an in-service training regarding ensuring apprpriate storage regarding cleaners, soaps, disinfectants, any other items that may pose a risk to residents in care, are to be locked up and inaccessible at all times. Submit follow-up proof of training by 5/25/26. Submit plan of correction by POC due date of 5/20/26.

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.

	Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:

	Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

LIC809 (FAS) - (06/04)

Page: 4 of 4