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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804104
Report Date: 05/19/2026
Date Signed: 05/20/2026 04:39:49 PM

Document Has Been Signed on 05/20/2026 04:39 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:LOLA MANORFACILITY NUMBER:
496804104
ADMINISTRATOR/
DIRECTOR:		ALLI, STANLEYFACILITY TYPE:
735
ADDRESS:6704 STURTEVANT DRIVETELEPHONE:
(707) 303-7922
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY: 4CENSUS: 4DATE:
05/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Stanley Alli, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Stanley Alli and Lola Alli licensee arrived later as well as House Manager Benjamin Merilatt. Facility currently has four (4) residents in care none of which are currently on hospice.

At approximately 9:30am LPA and licensee toured the building and grounds. LPA observed at least a 7 day supply of non-perishable food but not a 2 day supply of perishable food (deficiency cited, see 809D). Laundry soap cabinet has magnetic locking mechanism. All other cleaning products and laundry soaps are located in the garage and inaccessible to residents in care.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had grab bars. Water temperature in sink measured at 109.4 degrees F in the kitchen which is within the allowable range of 105 to 120 degrees F. Faucet in bathroom needs to be replaced and or repaired as it is loose and moves from side to side. Additionally, there is a hole that one can stick their fingers in on the right hand side (deficiency cited, see 809D).

Fire extinguishers were last inspected 5/8/26. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted on 2/4/26.

Stanley Alli Administrator Certificate 7032884735 expired 6/16/26. Annual fee due 5/11/26, balance due is $454. Fee notification given to Admin along with PIN for online payment.

Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2026
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: LOLA MANOR
FACILITY NUMBER: 496804104
VISIT DATE: 05/19/2026
NARRATIVE
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Continued from 809...

At approximately 11:00am LPA conducted a review of four (4) out of four (4) resident files. Three residents (R1, R2, and R3) are over the age of 60 but did not have current physician reports on file (deficiency cited, see 809D).

At approximately 11:30am LPA conducted a review of four (4) staff files. Staff (S1) did not have current first aid on file (deficiency cited, see 809D).

At approximately 12:00pm LPA and Licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked carts. R1 has prescription for medication guaifenesin 1200mg but medication on documented on Centrally Stored Medication log (deficiency cited, see 809D). LPA and licensee went over requirements for PRNs, PRN MARs, and that all doctors orders must be on file, current, and signed by the doctor. When LPA arrived LPA found both med carts, including one that contains narcotics, to be unlocked. Additionally, a small tote filled with prescription cough syrups for multiple residents unlocked. LPA discussed proper medication storage with licensee and House Manager (deficiency cited, see 809D).

At approximately 12:30pm LPA and licensee reviewed cash resources.

LPA and licensee discussed Emergency Disaster Plan. Licensee confirmed no updates but it was reviewed.

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
Surety Bond

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee 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: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/20/2026 04:39 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/19/2026 at 01:12 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: LOLA MANOR
FACILITY NUMBER: 496804104

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication 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
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Based on LPA observation, the licensee did not comply with the section cited above in that LPA observed both facility med carts, one which contains narcotics to be unlocked. Additionally, a small tote filled with prescription cough syrups for multiple residents was observed to be unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2026
Plan of Correction
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Facility to submit plan to conduct proper storage of medication training with all care staff and House Manager. Training to be conducted no later than 5/27/26. Training logs to be submitted to CCL bu no later than 5/27/26. Training log to include trainer, date of training, duration of training, topic, and attendee.
Type A
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and licensee record review, the licensee did not comply with the section cited above in that R1 has prescription for medication guaifenesin 1200mg but medication on documented on Centrally Stored Medication log, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2026
Plan of Correction
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Facility to submit plan to conduct proper medication documentation with all care staff and House Manager. Training to be conducted no later than 5/27/26. Training logs to be submitted to CCL bu no later than 5/27/26. Training log to include trainer, date of training, duration of training, topic, and attendee.
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: 05/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/20/2026 04:39 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/19/2026 at 01:12 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: LOLA MANOR
FACILITY NUMBER: 496804104

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and licensee observation, the licensee did not comply with the section cited above in that aucet in bathroom needs to be replaced and or repaired as it is loose and moves from side to side. Additionally, there is a hole that one can stick their fingers in on the right hand side, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2026
Plan of Correction
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Facility to submit pictures of repaired/replaced faucet in back bathroom by plan of correction due date.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in S1 did not have current first aid certificate, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2026
Plan of Correction
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Facility to submit current First Aid certifcate for S1 by plan of correction 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: 05/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/20/2026 04:39 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/19/2026 at 01:12 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: LOLA MANOR
FACILITY NUMBER: 496804104

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on LPA record review, the licensee did not comply with the section cited above in that R1, R2, and R3 did not have current medical assessments, they are were dated 2019, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2026
Plan of Correction
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Facilty to submit current physician reports for R1, R2, and R3 by plan of correction due date.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(d) The licensee shall meet the following food supply and storage requirements: (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and licensee observation, the licensee did not comply with the section cited above in that acility did not have 2 day supply of pershiable food, enough for four residents, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2026
Plan of Correction
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2
3
4
Facility to submit photos of 2 day supply of pershiable food, enough for four residents by plan of correction 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: 05/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2026


LIC809 (FAS) - (06/04)
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