<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803839
Report Date: 07/01/2025
Date Signed: 07/01/2025 05:39:04 PM

Document Has Been Signed on 07/01/2025 05:39 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:FAMILY HOUSEFACILITY NUMBER:
496803839
ADMINISTRATOR/
DIRECTOR:		GUZMAN ESTELITA, MARIA VFACILITY TYPE:
740
ADDRESS:6084 COUNTRY CLUB DRIVETELEPHONE:
(707) 843-7367
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 9CENSUS: 7DATE:
07/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Estelita Guzman-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:48 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 visit, on 7/1/25 at approximately 2:20pm, and met with Licensee/Administrator Estelita Guzman. LPA observed the Administrator, and four (4) caregivers working at the time of arrival. There are currently seven (7) residents in care.

Fire clearance is approved for nine (9) non-ambulatory, of which two (2) may be bedridden. Facility has nine (9) private resident rooms.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Facility has a required infection control plan. The facility has an emergency disaster plan as required.

LPA reviewed five (5) resident files; Resident files were complete.

LPA reviewed five (5) staff files. All staff have first aid and CPR certification. LPA reviewed staff training.

LPA toured the facility with the Administrator. Facility was clean and orderly during the inspection. Hot water was measured at 109.8 degrees Fahrenheit. All exits had auditory alarms. All exits were clear of obstruction. All facility walkways and ramps were free and clear of obstruction. All smoke alarms and carbon monoxide detectors were working properly during the inspection.Facility had sufficient lighting in resident rooms, bathrooms, hallways, and all common areas for residents in care. Bathrooms had grab bars, and mats in all showers for resident use.

Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2025
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 5
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)
Page: 2 of 5
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: FAMILY HOUSE
FACILITY NUMBER: 496803839
VISIT DATE: 07/01/2025
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
26
27
28
29
30
31
32
Continued from LIC809, dated 7/1/25.

The backyard deck has patio furnishings and shade umbrellas for resident use. There is a front yard ramp and two backyard ramps for resident use, and to use in the event of an emergency. Sufficient food supply was observed by the LPA. Sufficient supply of hygiene products, paper products, linens, cleaners/disinfectants, and personal protective equipment (PPE). Facility had emergency supplies to meet the "72 hour Shelter In Place requirements".

LPA is requesting the following documents be updated and submitted by 8/1/25:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster 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 Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate
Emergency Disaster Plan- Update as required/if changes-submit copy if any updates.
Infection Control Plan- Update as required/if changes-submit copy if any updates.


The following deficiencies were observed during the inspection:

LPA observed refrigerated medication in a small, unlocked refrigerator in the kitchen; LPA observed that the two medication bottles were left unlocked and accessible to residents in care. This deficiency will be cited, 87465(h)(2 Incidental Medical and Dental, see LIC809D.

Per LPA record reviews, Licensee lacked proof of conducting required quarterly drills per health & Safety Code. This deficiency will be cited, HSC1569.695(a)(2) Quarterly Emergency Disaster Drills, see LIC809D.



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

Appeal rights were provided.
Exit interview conducted with the Administrator, Estelita Guzman.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/01/2025 05:39 PM - It Cannot Be Edited


Created By: Dina Alviso On 07/01/2025 at 03:08 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: FAMILY HOUSE
FACILITY NUMBER: 496803839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2
87465(h)(2 Incidental Medical and Dental- 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 is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
LPA observed refrigerated medication in a small, unlocked refrigerator in the kitchen; LPA observed that the two medication bottles were left unlocked and accessible to residents in care, 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: 07/02/2025
Plan of Correction
1
2
3
4
Licensee to ensure all medications are centrally stored,, and inaccessible to residents in care. Hold an in-service with all staff regarding medication policy & procedures of the facility. Follow-up with proof of training by 7/9/25. Submit plan of correction by 7/2/25.
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: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2025


LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 07/01/2025 05:39 PM - It Cannot Be Edited


Created By: Dina Alviso On 07/01/2025 at 05:19 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: FAMILY HOUSE
FACILITY NUMBER: 496803839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Per LPA record reviews, Licensee lacked proof of conducting required quarterly drills per health & Safety Code, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
1
2
3
4
Licensee to ensure facility has a required emergency disaster drill, document the drill as required, with all pertinent information. Submit a copy of the drill for Department's review. Licensee to provide written statement of plan to ensure the quarterlydisaster drills are conducted as required by HSC. POC due 7/14/2025.
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: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5