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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803839
Report Date: 12/29/2025
Date Signed: 12/29/2025 03:50:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/24/2025 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20251224133925
FACILITY NAME:FAMILY HOUSEFACILITY NUMBER:
496803839
ADMINISTRATOR:GUZMAN ESTELITA, MARIA VFACILITY TYPE:
740
ADDRESS:6084 COUNTRY CLUB DRIVETELEPHONE:
(707) 843-7367
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:9CENSUS: 8DATE:
12/29/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lita Guzman-AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Resident's medication was not centrally stored as required
Medication was not provided to the resident as prescribed
Resident's room had a stained carpet upon move-in
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 12/29/2025 at approximately 10:00am, and met with Administartor Lita Guzman. LPA observed three caregivers on duty during the inspection.

Reporting party alleges a "resident's medication was not centrally stored as required, medication was not provided to the resident as prescibed, and resident's room had a stained carpet upon move-in."

The LPA reviewed resident records, facility records, conducted interviews with staff, and other related parties. The investigation revealed that R1's prescribed liquid medication had been left out on resident's dresser in their room; This medication was not centrally stored and locked up, as required, this deficiency will be cited, 87465(h)(2) Incidental Medical and Dental Care- The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication, see LIC9099D.

Continued on LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 21-AS-20251224133925
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: FAMILY HOUSE
FACILITY NUMBER: 496803839
VISIT DATE: 12/29/2025
NARRATIVE
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Per LPA's review of medication records, the MAR sheet, it was identified that on 10/9 there were two medications that were not provided to R1 as prescribed; One medication is provided once in the am, the other medication is provided twice a day, in the am and in the pm. In review of medication records, there was no information documented as to why these medications were not provided to R1. The Administrator could not provide a reason why the Mar was blank on 10/9 for these two medications R1 didn't receive. This deficiency will be cited, 87465(a)(4) Incidental Medical and Dental Care - A plan for incidental medical and dental care shall be developed by each facility.The licensee shall assist residents with self-administered medications as needed, see LIC9099D.

Per review of information obtained from interviews with the Administrator, and other parties, and tour of some facility resident rooms, the facility does have light colored carpet with some stains in different areas that are very visible. Administrator stated the carpet is older and they do clean it, but they will see about replacing the rug because they can see the stains the LPA was seeing/pointing out. LPA obtained some photos. These deficiency will be cited, 87303(a) Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services, see LIC9099D.

Per investigation, conducted interviews, review of facility records, and review of resident records, there was sufficient information obtained to support that the alleged violations occurred.

Based on record reviews, and interviews during this investigation, the allegations of "resident's medication was not centrally stored as required, medication was not provided to the resident as prescribed, and resident's room had a stained carpet upon move-in." is substantiated. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.

Exit interview was conducted with Emilita Guzman, Administrator.
Appeal Rights and report provided to the Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 21-AS-20251224133925
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: FAMILY HOUSE
FACILITY NUMBER: 496803839
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2025
Section Cited
CCR
87465(h)(2)
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87465(h)(2) Incidental Medical and Dental Care- The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
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Licensee/Administrator to ensure that all resident medications are centrally stored as required. Hold an in-service with all staff to review medication policies of the facility. Submit proof of training by 1/8/26.
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R1's prescribed liquid medication had been left out on resident's dresser in their room; This medication was not centrally stored and locked up, as required, This is a risk to the health & safety of residents' in care.
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Submit a plan regarding future compliance with this regulation, and plan of correction by 12/30/25.
Type A
12/30/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care - A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Per LPA's review of medication records, the MAR sheet, it was identified that on 10/9
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Licensee/Administrator to ensure that all resident medications are provided to residents' as required. Hold an in-service with all staff to review medication policies of the facility. Submit proof of training by 1/8/26.
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there were two medications that were not provided to R1 as prescribed; One medication is provided once in the am, the other medication is provided twice a day, in the am and in the pm. Administrator could not provide any information why these medications were not provided. This is a risk to residents' health & safety.
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Submit a plan regarding future compliance with this regulation, and plan of correction by 12/30/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/24/2025 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20251224133925

FACILITY NAME:FAMILY HOUSEFACILITY NUMBER:
496803839
ADMINISTRATOR:GUZMAN ESTELITA, MARIA VFACILITY TYPE:
740
ADDRESS:6084 COUNTRY CLUB DRIVETELEPHONE:
(707) 843-7367
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:9CENSUS: 8DATE:
12/29/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lita Guzman-AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Violation of residents personal rights
Responsible party was not notified of resident's fall in a timely manner
Meals provided to the residents' lack nutritious items, like greens, vegetables and/or salad
INVESTIGATION FINDINGS:
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5
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 12/29/2025 at approximately 10:00am, and met with Administartor Lita Guzman. LPA observed three caregivers on duty during the inspection.

Reporting party alleges "violation of residents personal rights, responsible party was not notified of resident's fall in a timely manner, and meals provided to the residents' lack nutritious items, like greens, vegetables and/or salad."

The LPA reviewed resident records, facility records, conducted interviews with staff, and other related parties. The investigation revealed that R1 had a fall 10/9/25 pm, was assessed by staff, and identified to not need emergencymedical services. Per interviews, responsible party (s) were notified of the fall on 10/10/25 in the late morning, by the Administrator. Administrator stated that when needing to speak privately with residents and/or responsible parties, they will meet in the resident's room or can meet in the back of the house common area, if empty.

Continued on LIC9099C..
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20251224133925
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: FAMILY HOUSE
FACILITY NUMBER: 496803839
VISIT DATE: 12/29/2025
NARRATIVE
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Facility had a sufficient supply of food, a variety of food items, including fruits and vegetables/greens, for resident meals.

There was insufficient information obtained in the investigation to support that the allegations "violation of residents personal rights, responsible party was not notified of resident's fall in a timely manner, and meals provided to the residents' lack nutritious items, like greens, vegetables and/or salad." had occurred.

The LPA discussed personal rights of residents in care, incidents/reporting incidents, and food service regulations, with the Administrator during the inspection.

Based on record reviews, interviews conducted, and information obtained, there is no evidence to support the violations occurred. The allegations are UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies cited.
Exit interview was conducted with Emilita Guzman, Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20251224133925
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: FAMILY HOUSE
FACILITY NUMBER: 496803839
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2026
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303(a) Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services. This requirement was not met as evidenced by: tour of some facility resident rooms, the facility does have light colored carpet with
1
2
3
4
5
6
7
Licensee/Administrator to ensure the facility carpet is maintained in a clean manner, not dirty and stained, and/or replace the rug if needed. Submit how the facility will ensure compliance with this reguation, how this deficiency was corrected, and how it will be maintained. POC due 1/19/26.
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some stains in different areas that are very visible. Administrator stated the carpet is older and they do clean it, but they will see about replacing the rug because they can see the stains the LPA was seeing/pointing out. This is a risk to residents' personal rights.
8
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10
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14
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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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6