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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803579
Report Date: 01/06/2026
Date Signed: 01/06/2026 03:00:30 PM

Document Has Been Signed on 01/06/2026 03:00 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:BENSHANTE PLACEFACILITY NUMBER:
496803579
ADMINISTRATOR/
DIRECTOR:		MILLER, DEBBIEFACILITY TYPE:
735
ADDRESS:500 LOS ARBOLES WAYTELEPHONE:
(707) 978-5989
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 4CENSUS: DATE:
01/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Debbie Miller - AdminstratorTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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At approximately 11:55 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced to conduct a required - 1 Year Inspection, and was met by caregiver J.M. who called Licensee/Administrator Debbie Miller who arrived at 12:45 PM to assist with today's inspection. Facility currently cares for four clients, all of which were away at day programming or in the community during this inspection. Licensee is working with the Central Application Bureau to effect a change of location to a nearby home owned by licensee (copy of deed obtained) The move has a target date of February 13th, 2026 (lease on current property ends February, 28th 2026)

Fire clearance approval is for four (4) ambulatory clients. Facility has an infection control plan as required. Facility has an emergency disaster plan as required. Fire extinguishers one (1), were serviced and tagged as required, dated 12/10/2025. All exits were cleared and free of obstruction.

Last emergency disaster drill was conducted on 09/24/2025. Administrator understands that the drills are held quarterly, ensuring one is an evacuation drill.

LPAsreviewed four (4) resident files. P&I monies were intact and records were maintained as required.
Medicines were found to be centrally stored and secure and a spot check of medicines shows them to have been administered correctly, however the documentation of administration was missing in two (2) of five (5) spot checks of documentation and licensee is reminded to insure continuous accurate documentation of medicine administration and a technical violation of (80075(b)(5)(C) was issued.

LPA reviewed four (4) staff files. All staff had training, including first aid. All staff had criminal record clearance as required.
Continued on LIC809
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2026
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BENSHANTE PLACE
FACILITY NUMBER: 496803579
VISIT DATE: 01/06/2026
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Continued from LIC809
Hot water was checked at 113. degrees Fahrenheit. Facility was found to be at a comfortable temperature. Sufficient food supply. Sufficient hygiene products, cleaners/disinfectants, paper products, and furnishings for resident use. There was a sufficient supply of personal protective equipment (PPE).

LPA is requesting the following documents be updated and submitted to Community Care Licensing by 02/05/2026:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Surety bond
Resident Roster

Technical violation is cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), may result in a civil penalty assessment in the future.

This report was reviewed with licensee Debbie Miller and Appeal rights were given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026
LIC809 (FAS) - (06/04)
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