496803630-12-9-2025-21-AS-DALO-DP7UMQ-20251209144245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803630
Report Date: 12/09/2025
Date Signed: 12/09/2025 02:42:58 PM

Document Has Been Signed on 12/09/2025 02:42 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:	PETERSON LANE HOME		FACILITY NUMBER:	496803630
ADMINISTRATOR/ DIRECTOR:	NARCISO, JENNICA A		FACILITY TYPE:	734
ADDRESS:	1618 PETERSON LANE		TELEPHONE:	(707) 978-2573
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 5		CENSUS: 5	DATE:	12/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Abbie (Jennica) Narciso-Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:50 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 inspection, on 12/9/25 at approximately 10:00am, and met with Abbie Narciso, Administrator/RN. LPA observed two caregivers/DSPs on duty during the inspection. There are five (5) clients residing in the home; Four (4) of the clients are at day program. Facility is fire cleared for five (5) clients that are non-ambulatory, of which five (5) may be bedridden. Facility has a signal system on all exit doors. The facility has a permanent generator as a 2nd required power source. The generators run a check once every week to ensure they are working properly. The fire extinguishers were serviced and tagged as required. All exits were unobstructed. Smoke alarms are hard wired, home is fire sprinkled, and has two carbon monoxide detectors. Disaster drills/fire drills were being conducted by staff as needed, per record review. Hot water was measured at 110.4 degrees Fahrenheit. All bathrooms have grab bars, and roll in shower area for clients use. The facility had a sufficient supply of food, hygiene products, linens, cleaners, incontinent supplies, paper supplies, and a large supply of personal protective equipment. Facility had sufficient furnishings for client use. All common areas, hallways, and resident rooms have sufficient lighting available for clients in care. The interior and exterior of the home were observed to be clean, maintained, and orderly. Facility has emergency food, water, and miscellaneous supplies to meet "72 hour shelter in place" requirements. Facility has a portable generator if needed. LPA observed the facility to be at comfortable temperature during the inspection. All medications were locked and inaccessible to clients, and all others that do not handle medications. Cleaners/disinfectants were locked and inaccessible to clients in care. Continued on LIC809C..

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025

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: PETERSON LANE HOME	FACILITY NUMBER: 496803630
	VISIT DATE: 12/09/2025

NARRATIVE

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LPA reviewed five (5) resident files.

LPA reviewed five (5) staff files. All staff have criminal record clearance as required. LPA reviewed staff training. All staff had required first aid certification, and CPR certification as required. Staff handling medications were all licensed nurses on each shift.

LPA requested the following updated documents by 1/9/2026:
LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
Emergency Disaster Plan-Submit copy if any changes- no changes,please sign/date & submit last page
LIC 400- Affidavit regarding Client Cash Resources
Surety Bond-if handling cash
Register of residents

Per review of resident C1 incident on 12/1/25, client was not provided am medication as prescribed. Facility staff/S2 signed off in the MAR that am medications (meds), two (2) separate meds, had been provided to C1, but the meds were observed later in the afternoon to still be in the med bubble packs. One (1) medication was able to be provided to C1 late, but the other medication was no longer able to be provided, per Physician that was contacted regarding missed meds. Staff monitored client C1 for any observed changes due to medication error. This incident is a deficiency and will be cited, 80075(b)(5)(B) Health Related Services- Once ordered by the physician the medication is given according to the physician's directions, see LIC809D.

Deficiencies cited from California Code of Regulations,Title 22, Division 6, of California Regulation and/or from Health and Safety Code.

Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with the Administrator, Abbie Jennica Narciso. Appeal rights provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/09/2025 02:42 PM - It Cannot Be Edited

Created By: Dina Alviso On 12/09/2025 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: PETERSON LANE HOME	FACILITY NUMBER: 496803630
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(b)(5)(B)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review, Per review of resident C1 incident on 12/1/25, client was not provided am medication as prescribed. Facility staff/S2 signed off in the MAR that am medications (meds), two (2) separate meds, had been provided to C1, but the meds were observed later in the afternoon to still be in the med bubble packs. One (1) medication was able to be provided to C1 late, but the other medication was no longer able to be provided, per Physician that was contacted, 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: 12/10/2025
	Plan of Correction
1 2 3 4	LICENSEE/ADMINISTRATOR, RN NARCISO, HAS CORRECTED THIS DEFICIENCY BY HOLDING AN IN-SERVICE TRAINING, ON 12/5/25, WITH ALL LICENSED NURSING STAFF OF THE FACILITY. LPA PROVIDED PROOF OF TRAINING. POC IS CLEARED 12/9/2025.

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: 12/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025

LIC809 (FAS) - (06/04)

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