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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803657
Report Date: 11/10/2025
Date Signed: 11/10/2025 12:33:37 PM

Document Has Been Signed on 11/10/2025 12:33 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:HOPE HOUSEFACILITY NUMBER:
496803657
ADMINISTRATOR/
DIRECTOR:		DEBBIE MCCULLOCHFACILITY TYPE:
735
ADDRESS:1550 N DUTTONTELEPHONE:
(707) 293-3138
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 12CENSUS: 10DATE:
11/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:44 AM
MET WITH:Cassie Reed (Program Manager)TIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Cassie Reed, Program Manager. Annual fees are current.

At approximate 9:00am LPA initiated file review of ten client's files and five staff files. All clients have medical assessments, two out of ten clients' care plans needs to be updated. Staff have required annual training hours and CPR/1st aid certificates updated. Required postings were observed.

LPA/Program Mgr initiated a tour of the facility around 11:30am and made the following observations: Facility was a comfortable temperature, Cleaning supplies are stored in a closet that was locked at time of inspection. Client rooms were furnished per regulation. Extra hygiene products and linens were available. Fire extinguisher was last inspected April 2025. Carbon Monoxide and some detectors located throughout the facility were tested and operational. Most recent disaster drills were conducted 10/18/25. Water temperature in client bathrooms measured at 114.6 and 112.6 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Facility does not have at least two days of perishable, but there was one week of non-perishable foods. Also, LPA/Program mgr noticed expired food located in the food pantry area located in the garage where the facility keeps their food stored (pictures taken). The main refrigerator located in the kitchen had a lock and it was observed unlocked during the visit. According to staff, they do lock the refrigerator at night and staff leaves snacks available in client's dining table. Facility does not handle cash resources.
Continues on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2025
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 6
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HOPE HOUSE
FACILITY NUMBER: 496803657
VISIT DATE: 11/10/2025
NARRATIVE
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Continued from LIC809...

Medications were reviewed, centrally stored and locked in the office. Administrator Certificate for Administrator Debbie McCulloch 7016280735 , expired July 2024. LPA confirmed ACS packet has been submitted, but administrator is not under any re-certification pending nor active list. Program Manager stated that they will be submitting their recent administrator certification and needed documentation to change administrators in the system. LPA provided documentation regarding a change of administrator to be submitted to CCL with the following:

Documentation Needed for Change of Administrator:

- LIC 200 indicating change of administrator.
- LIC 501 Personnel Record.
- LIC 500 Personnel Report (indicating amount of hours to be spent at the facility).
- LIC308 Designation of facility responsibility.
- LIC 503 Health Screening Report.
- Copy of Administrator's certificate.
- Detailed employment/education history.
- Board Resolution stating who the Administrator is and that the board has approved of the individual.

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

Exit interview was conducted with Program Manager and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/10/2025 12:33 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/10/2025 at 12:04 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: HOPE HOUSE
FACILITY NUMBER: 496803657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(1)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Program Manager observation and interview, the facility failed to ensure that food was not kept beyond their expiration dates, multiple jared, canned and boxed foods with expiration dates in Nov 2025 were observed in the food pantry located in the garage, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2025
Plan of Correction
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Program Manager agrees to ensure food is stored in a healthful manner at all times. Program Manager agrees to dispose expired food and will hold an in-service training for all staff on how to handle food storage and to ensure no food is kept beyond its expiration. LIC 9098 - Certification that all expired food has been disposed to be submitted to CCL by POC date of 11/11/25.
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:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/10/2025 12:33 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/10/2025 at 12:04 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: HOPE HOUSE
FACILITY NUMBER: 496803657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Program Manager observation, interview and record review, the licensee did not comply with the section cited above during annual required visit, it was determined that current administrator on file has an expired adm. certificate - expired on July 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2025
Plan of Correction
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Facility to submit candidate for Administrator and all required paperwork: LIC200, LIC500, LIC308, LIC501, detailed employment/education history, copy of current and active Administrator certificate, and board resolution by plan of correction due date.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Program Manager observation and interview, the faciltiy did not comply with the section cited above by not ensuring one week nonperishable food supply which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2025
Plan of Correction
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Program Manager agrees to at all times have one week supply of nonperishable food for clients in care and they will submit LIC 9098 self certification to ensure above to CCL by POC 11/24/25.
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:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 11/10/2025 12:33 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/10/2025 at 12:04 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: HOPE HOUSE
FACILITY NUMBER: 496803657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Program Manager observation, records review and interview, the licensee did not comply with the section cited above in 2 out of 10 client's care plans have not been updated within the last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2025
Plan of Correction
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Program Manager agrees to upgrade care plans with clients/responsible party to acknowledge and sign clients' care plans. Program Manager will submit LIC 9098 self certification to CCL certifying that care plans had been updated by POC due date.
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:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2025


LIC809 (FAS) - (06/04)
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