496803915-5-15-2025-21-AS-DALO-DGQ36D-20250515175809

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803915
Report Date: 05/15/2025
Date Signed: 05/15/2025 05:58:18 PM

Document Has Been Signed on 05/15/2025 05:58 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:	MARIE'S CARE HOME		FACILITY NUMBER:	496803915
ADMINISTRATOR/ DIRECTOR:	BISCOCHO, LIZA		FACILITY TYPE:	740
ADDRESS:	7334 CARIOCA CT.		TELEPHONE:	(707) 794-0591
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	05/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:40 PM
MET WITH:	Liza Biscocho- Administrator		TIME VISIT/ INSPECTION COMPLETED:	06:15 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 5/15/25 at approximately 2:40pm, and met with caregivers Charles and Chadaporn, Caregivers contacted Administrator Liza Biscocho and notified them of the LPA's arrival. Administrator arrived to meet with the LPA shortly after being contacted by the staff. Facility has an approved hospice waiver for three (3) residents. Facility has an approved dementia plan of operation. Facility has an emergency disaster and evacuation plan as required. Facility has an infection control plan as required. Per record reviews, last emergency disaster drills were conducted on 5/8/25 a water, electrical, and gas shut off/outage, and on 2/17/25 an evacuation drill. Fire clearance is approved for six (6) non-ambulatory, of which one(1) may be bedridden. Facility has six (6) residents in care; No hospice residents at this time. LPA reviewed six (6) resident files. Resident files were complete. LPA reviewed five (5) staff files. All staff have criminal record clearance as required. All staff have required training. All staff have first aid, and CPR certification. Facility water was measured at 120. degrees Fahrenheit, which is within regulation. All exits were free and clear of obstruction. Smoke alarms are also carbon monoxide detectors, all worked properly during the inspection. Continued on LIC809C..

Bethany Moellers	TELEPHONE: (707) 588-5040
Dina Alviso	TELEPHONE: (707) 588-5082
	DATE: 05/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025

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: MARIE'S CARE HOME	FACILITY NUMBER: 496803915
	VISIT DATE: 05/15/2025

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Food supply was sufficient. Facility had sufficient furnishings for resident use, and all areas of the facility have sufficient lighting for residents in care. All bathrooms had grab bars, and showers had non-slip flooring/mats for resident use. Facility had a sufficient supply of linens, paper products, cleaners/soaps/disinfectants, and personal protective equipment (PPE). Facility was observed by the LPA to be clean and orderly, and at a comfortable temperature during the inspection. Facility had a supply of emergency food and water supplies to meet the "72 hour shelter in place" requirements.

LPA are requesting the following documents be updated and submitted to CCL by 6/15/2025:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610 - Emergency Disaster Plan-update if needed-submit if changes
Copy of Current Liability Insurance
Copy of current Administrator Certificate
Copy of updated Infection Control Plan- update if needed- submit if changes
Copy of current resident Roster

There were no deficiencies cited today.
Exit interview conducted with the Administrator Liza Biscocho.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025

LIC809 (FAS) - (06/04)

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