496803379-3-17-2025-21-AS-SHAN-DEUTZ6-20250317150950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803379
Report Date: 03/17/2025
Date Signed: 03/17/2025 03:51:24 PM

Document Has Been Signed on 03/17/2025 03:51 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:	HILL TERRACE		FACILITY NUMBER:	496803379
ADMINISTRATOR/ DIRECTOR:	CASTANEDA, RAMIRO ERNESTO		FACILITY TYPE:	740
ADDRESS:	922 COTTONWOOD COURT		TELEPHONE:	(707) 981-7784
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY: 5	TOTAL ENROLLED CHILDREN: 0	CENSUS: 1	DATE:	03/17/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:20 PM
MET WITH:	Kevin Castaneda, Licensee		TIME VISIT/ INSPECTION COMPLETED:	03:15 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	License Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an annual required – 1 yr. visit of the facility. LPA was welcomed by Licensee Kevin Castaneda & Administrator Ramiro Castaneda. Facility is a single story four-bedroom residence with 2 bathrooms and a fire clearance for 5 non-ambulatory residence. There is a total of one resident in care, without a diagnosis of dementia. There are no residents currently on Hospice. LPA toured the facility on 3/17/2025 at 1:40 PM with Licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices; all auditory devices were working properly. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 119.5 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility on 3/17/2025. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the laundry room/garage. Dangerous items were found stored inaccessible to residents with dementia There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations # 87307 on 3/17/2025 at 2:00 PM. Continue LIC 809-C

Bethany Moellers	TELEPHONE: (707) 588-5026
Shannan Hansen	TELEPHONE: 707-588-5026
	DATE: 03/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025

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 2

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: HILL TERRACE	FACILITY NUMBER: 496803379
	VISIT DATE: 03/17/2025

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

A review of resident & two staff records was conducted. LPA reviewed resident file at 2:05 PM on 3/17/2025 and learned that resident has an updated re-appraisals/needs & care plans and physician’s assessments (LIC 602A) are updated as required by Title 22 Regulations on file.

Facility to ensure that approved Admissions Agreements are always posted and/or accessible to public view in the facility as per Title 22 Regulations # 87507 (e)(2) Admissions Agreement “The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility.”

Medications were centrally stored in locked cabinet in facility kitchen. The Medications of one resident were found to be given according to physicians’ directions on 3/17/2025 at 2:30 PM.

Continue LIC 809-C

LPA reviewed a sample of staff records at 1:20 PM on 3/17/2025 and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. LPA was presented with proof of CPR & 1^st Aid certification for staff that files were reviewed. Ramiro Castaneda Administrator Certificate # 7035606740 expires on 4/21/2026. Licensee Kevin Castaneda Administrator Certificate #7035607740 expires 10/8/2026. Disaster drills are conducted quarterly, in different shifts with the last being conducted 12/9/2024. LPA suggested review facility emergency plan to ensure accuracy according to the needs of facility residents.

No citations/deficiencies given at today's inspection
LPA Hansen is requesting Licensee to update the following documents by 4/7/2025:

LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changes)
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025

LIC809 (FAS) - (06/04)

Page: 2 of 2