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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803876
Report Date: 04/01/2025
Date Signed: 04/01/2025 01:35:06 PM

Document Has Been Signed on 04/01/2025 01:35 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:CWH SANTA ROSA, INCFACILITY NUMBER:
496803876
ADMINISTRATOR/
DIRECTOR:		CLARK, CATHERINEFACILITY TYPE:
740
ADDRESS:100 CREEK WAYTELEPHONE:
(707) 526-4400
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 5TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
04/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Catherine Clark- AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Alviso and Contreras, conducted a Required- 1 Year visit, on 4/1/25 at approximately, and met with Administrator/Licensee Catherine (Cathy) Clark. Currently there are four (4) residents in care.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. Facility has a required infection control plan. Facility has a required emergency disaster plan. Fire clearance is approved for five (5) non-ambulatory, which includes two (2) bedridden in room #3 only.

LPAs reviewed four (4) resident files. All files were complete.

LPAs reviewed three (3) staff files. One staff, S2, was not associated as required. S2 lacked first aid certification as required; These deficiencies are cited, see LIC809D. S2 not being associated is an immediate civil penalty, assessed in the amount of $100, see LIC421BG.

LPA's toured the facility with the Administrator. Hot water was measured at 118. degrees Fahrenheit. All exits were clear and free of obstruction. All exits had auditory alarms. All postings were up and visible to all entering the home. Facility had sufficient food supply. Facility had sufficient supply of cleaners, paper products, and personal protective equipment (PPE). All bathrooms had grab bars, and shower mats for resident use. Medications were locked and inaccessible to residents in care.

LPA are requesting the following documents be updated and submitted to CCL by 6/23/2025:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
Continued on LIC809C...
Bethany MoellersTELEPHONE: (707) 588-5040
Dina AlvisoTELEPHONE: (707) 588-5082
DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2025
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 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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Document Has Been Signed on 04/01/2025 01:35 PM - It Cannot Be Edited


Created By: Dina Alviso On 04/01/2025 at 12:38 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: CWH SANTA ROSA, INC
FACILITY NUMBER: 496803876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA record review S2, did not have required First Aid Certification training.The licensee did not comply with the section cited above in [1] out of [3] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2025
Plan of Correction
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Licensee to ensure that S2 receives First Aid Certification training as required by regulation. Licensee to submit proof of S2 obtaining First Aid Certification. POC due 4/2/2025.
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:
TELEPHONE: (707) 588-5040
Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (707) 588-5082
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/01/2025 01:35 PM - It Cannot Be Edited


Created By: Dina Alviso On 04/01/2025 at 12:38 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: CWH SANTA ROSA, INC
FACILITY NUMBER: 496803876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA record review S2 was not associated with facility as required. Immediate civil penalty assesed in the amount of $100, the licensee did not comply with the section cited above in [1] out of [3] file reviews which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2025
Plan of Correction
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Licensee to ensure that employee is associated with facility as required. Licensee to submit LIC9182 and photo ID required by 4/02/2025 to associate S2. POC due 4/02/2025
Type B
Section Cited
CCR
87555(b)(21)

87555(b)(21) General Food Service Requirements- Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA observation refrigerator in need of cleaning including crumbs, spilling and dry food throughout the refrigerator and freezer. LPA obtained photos 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: 04/18/2025
Plan of Correction
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Licensee to ensure that refrigerator shall be kept clean and sanitized as required by regulation. Licensee to have refrigerator cleaned and submit POC to ensure cleanliness by 4/18/2025.
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:
TELEPHONE: (707) 588-5040
Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (707) 588-5082
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/01/2025 01:35 PM - It Cannot Be Edited


Created By: Dina Alviso On 04/01/2025 at 12:54 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: CWH SANTA ROSA, INC
FACILITY NUMBER: 496803876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(9)

87555(b)(9) General Food Service Requirements-The following food service requirements shall apply: Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA observation, food in freezer was expired, sausage meat and steak meat fillet mignon date expired 2023. LPA discussed food storage and food safety with administrator and stated their understanding regarding food storage, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2025
Plan of Correction
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Licensee to ensure all food stored in freezer and refrigerator are stored using procedure which protect the safety, acceptability and nutritive values of the food items. Licensee to submit POC in how the facility will remain compliant with the regulation. POC due 4/02/2025.
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:
TELEPHONE: (707) 588-5040
Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (707) 588-5082
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: CWH SANTA ROSA, INC
FACILITY NUMBER: 496803876
VISIT DATE: 04/01/2025
NARRATIVE
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LIC610 - Emergency Disaster Plan
Copy of Current Liability Insurance
Copy of current Administrator Certificate
Copy of updated Infection Control Plan-if any changes

Deficiencies 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.

Exit interview conducted with Administrator Catherine Clark.
Appeal Rights provided to the Licensee/Administrator Catherine Clark.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
LIC809 (FAS) - (06/04)
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