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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803960
Report Date: 04/02/2025
Date Signed: 04/02/2025 04:06:00 PM

Document Has Been Signed on 04/02/2025 04:06 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:ELSA'S HOMEFACILITY NUMBER:
496803960
ADMINISTRATOR/
DIRECTOR:		WAINAINA, KENNEDYFACILITY TYPE:
740
ADDRESS:10 CREEKVIEW COURTTELEPHONE:
(707) 539-5625
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 5DATE:
04/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Kennedy Wainaina, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by co-Administrator Mercado "Alfonso" Galvez. Administrator Kennedy Wainaina arrived later.

At approximately 9:30am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms except room #6 were clean and in good repair. Room #6 has a pervasive urine incontinence odor that is noticeable throughout the facility as well as specifically in room #6 . LPA and Admin discussed on going issue of incontinence odor present in facility due to R6 persistently urinating on their carpet in their bedroom (deficiency cited, see 809D). LPA asked Admin about using chucks on the floor or pads designed to collect urine, but Admin advised LPA that R6 refuses to have those on the floor and Admin advised using chucks would pose a slipping hazard. LPA and Admin discussed replacing carpet with faux wood flooring or flooring that is designed to be waterproof like linoleum so that the urine can be cleaned easily and often. Admin is already using rubber-backed mats to try and mitigate urine from further soaking in to the existing carpet. Admin washes carpets during the day for use at night, as it is during this time that R6 urinates on the carpet. LPA and Admin discussed continuing to use rubber-backed mats to mitigate and/or prevent R6 from slipping.

Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2025
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: ELSA'S HOME
FACILITY NUMBER: 496803960
VISIT DATE: 04/02/2025
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Continued from 809...

LPA and Admin observed facility to have extra hygiene products and linens available. Resident bathrooms had required bath mats and grab bars. Water temperature in sink accessible to residents in care measured at 108.5 degrees F which is within the allowable range of 105 to 120 degrees F.

Facility garage stores refrigerator and freezer for extra food storage as well as pantry items. Garage also houses the majority of facility's cleaning supplies stored in a tall metal cabinet with locking feature. LPA and Admin observed both the door and the tall metal cabinet containing all the cleaning supplies in the garage to be unlocked and unattended (deficiency, see 809D). Hall space in front of garage door houses a cabinet with lotions and creams that need to be locked. Admin will add lock to cabinet to ensure creams and lotions are inaccessible to residents.

Fire extinguishers were last inspected 2/10/25. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired and serviced by a vendor and were last serviced January 2025. Facility’s last quarterly disaster drills were conducted 3/22/25. Facility has a backup generator for use during a power outage. Perimeter fence in backyard in disrepair, fence not sturdy and visible signs of green and black substance present on bottom of wood panels. Some wood panels are broken and/or not attached to the fence securely (deficiency cited, see 809D).

At approximately 12:30pm LPA conducted a review of five [5] resident records. R1, R2, R3, and R4 had medical assessments dated 2023 or earlier (deficiency cited, see 809D). LPA discussed regulation 87463(h): The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. (2) Documentation of a resident's refusal to receive an annual routine visit, or if applicable, their representative's refusal on their behalf, shall be added to the resident's record. (3) If a resident refuses to receive an annual routine visit, or if applicable, their representative refuses an annual routine visit on their behalf, but later agrees to one, documentation of the annual routine visit shall be added to the resident’s record. LPA discussed with Admin MA for R1. Two MAs were present in file: one dated January 2023 and the other May 2023. MA dated

Continued on 809C(2)...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
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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: ELSA'S HOME
FACILITY NUMBER: 496803960
VISIT DATE: 04/02/2025
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Continued from 809C...


January 2023 shows diagnosis of dementia and bedridden ambulatory status, with physician indicating R1 had been their patient for 3 days. MA dated May 2023 shows diagnosis of MCI and ambulatory status of non-ambulatory, with physician noting R1 has been their patient for 1 day. LPA and Admin discussed accuracy of downgraded diagnosis and ambulatory status. Admin will follow up with R1's current physician for accuracy of diagnoses.

At approximately 2:00pm LPA conducted review of five [5] staff records. All required documentation present.

At approximately 3:15pm LPA and Admin discussed medication and medication records. Medication is centrally stored in a locked closet. Admin will be working with staff to go over medication management and proper documentation.

Kennedy Wainaina Administrator Certificate 7025718740 expires 6/29/25.



Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

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

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

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/02/2025 04:06 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/02/2025 at 03:33 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: ELSA'S HOME
FACILITY NUMBER: 496803960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that both the garage door and the tall metal cabinet containing all the cleaning supplies in the garage to be unlocked and unattended, 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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2
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Facility to submit LIC9098 self-certifying they will keep the garage door locked and/or the cleaning supplies cabniet locked at all times.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/02/2025 04:06 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/02/2025 at 03:33 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: ELSA'S HOME
FACILITY NUMBER: 496803960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that perimeter fence in backyard in disrepair, fence not sturdy, and visible signs of green and balck substance present on bottom of wood panels. Some wood panels are broken and/or not attached to the fence securely, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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Facility to submit pictures of repaired/replaced fence by plan of correction due date.
Type B
Section Cited
CCR
87463(h)(1)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on LPA observation and record review, the licensee did not comply with the section cited above in that R1, R2, R3, and R4 had medical assessments dated 2023 or earlier, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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4
Facility to submit current medical assessments (or visit summary indicating annual routine visit was conducted examining items required per regulation 87458) routine for R1, R2, R3, and R4 by plan of ocrrection due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 04/02/2025 04:06 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/02/2025 at 03:33 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: ELSA'S HOME
FACILITY NUMBER: 496803960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that Room #6 has a pervasive urine incontinence odor that is noticeable throughout the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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2
3
4
Facility will replace carpet in room #6. Replacement will either be new carpet, faux wood flooring, or flooring that is designed to be waterproof like linoleum so that the urine can be cleaned easily and often. Facility will continue to work with resident occupant of room #6 to manage incontinence. Facility to submit pictures of replacement by plan of correction due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2025


LIC809 (FAS) - (06/04)
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