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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803613
Report Date: 11/05/2025
Date Signed: 11/05/2025 02:02:03 PM

Document Has Been Signed on 11/05/2025 02:02 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:ALLIED INTEGRATION SERVICESFACILITY NUMBER:
496803613
ADMINISTRATOR/
DIRECTOR:		VANDERVILLE, ERICFACILITY TYPE:
775
ADDRESS:50 EXECUTIVE AVETELEPHONE:
(707) 586-1799
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 30CENSUS: 14DATE:
11/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Catherine Wheaton-Program DirectorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a Required -1 Year inspection, approximately 10:15am on 11/5/25, and met with Program Director, Catherine Wheaton. Administrator, Eric Vanderville, was not able to meet with the LPA, due to being out for the day.

Currently there are fourteen (14) clients enrolled in day program services; Today, there are eleven clients in the community with staff supervision. Two clients were on-site with staff supervision.

Facility is fire cleared for thirty (30) clients, of which four (4) may be non-ambulatory. Facility has an infection control plan as required. Facility has an emergency disaster plan as required. Per review of emergency disaster drills, a fire/evacuation drilll was conducted on 9/18/25.

Facility has no medication assistance available as part of the client day program services. Per Program Director, no medications on-site, and clients receive no medication assistance during day program services.

The LPA reviewed six (6) client files. All client files were complete.

The LPA reviewed five (6) staff files. All staff had required criminal record clearance. Staff had required training, including first aid certification, and CPR certification.

LPA toured the facility with the Program Director. Hot water was measured at 110.4 degrees Fahrenheit. All exits were free and clear of any obstructions. Facility was clean and orderly. Bathrooms, two (2), were clean, and had soap and paper towels available for client use.
Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2025
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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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: ALLIED INTEGRATION SERVICES
FACILITY NUMBER: 496803613
VISIT DATE: 11/05/2025
NARRATIVE
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LPA observed numerous activity supplies. LPA observed that the facility had sufficient lighting throughout the common areas. Facility had a required carbon monoxide detector. Disinfectants/cleaners were locked up and inaccessible to clients in care. Facility has automatic sanitizer stands in different areas of the day program for client use. Client lunches are stored in a refrigerator in the small kitchenette area. Facility has a sufficient supply of sanitizer, soap, paper products, cleaners/disinfectants, and personal protective equipment (PPE).

LPA discussed regulations regarding records, and criminal record clearances. LPA advised the Program Director to review, and ensure all client and staff files are complete. Ensuring all required documents are in the file, and updated documents are completed as required by regulations. Program Director stated their understanding of the above. LPA notified Program Director to reach out to the LPA if they have any questions regarding the above.

Licensee to submit the following annual forms by 12/5/25:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610D-(9 page) Emergency Disaster Plan- Review &update if needed. Submit copy
LIC400-Affidavit Regarding Client Cash Resources- complete the form
LIC402-Surety Bond (if handling client cash)
Infection Control Plan- Review &update if needed. Submit copy

Following deficiency was identified during the inspection and will be cited, see LIC809D.
Per LPA's review of guardian personnel summary, and review of S3's clearance record in Guardian, S3 was not associated to the facility. The deficiency will be cited, 82019(f) Criminal Record Clearance- A licensee or applicant for a license may request of a transfer of a criminal record clearance from one state licensed facility to another. An immediate civil penalty fine of $100 is being assessed today, as required.

The following deficiency(s) was 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.
Appeal Rights provided.
Exit interview conducted with the Program Director, Catherine Wheaton.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2025 02:02 PM - It Cannot Be Edited


Created By: Dina Alviso On 11/05/2025 at 12:55 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: ALLIED INTEGRATION SERVICES
FACILITY NUMBER: 496803613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82019(f)
82019(f) Criminal Record Clearance- A licensee or applicant for a license may request of a transfer of a criminal record clearance from one state licensed facility to another, or from TrustLine to a state licensed facility by providing the required documents to the Department:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of guardian personnel summary, and review of S3's clearance record in Guardian, S3 was not associated to the facility. An immediate civil penalty fine of $100 is being assessed today, as required, the licensee did not comply with the section cited above in [1] out of [total 6] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2025
Plan of Correction
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Licensee/Administrator to ensure all staff have fingerprint clearance and are associated to the facility as required. Associate staff S3 to the facility by accessing your guardian account and completing an association application and/or submit required documents, per regulation, to the Department to have S3 associated to the facility. POC due 11/7/2025.
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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2025


LIC809 (FAS) - (06/04)
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