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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804107
Report Date: 07/14/2026
Date Signed: 07/14/2026 12:55:44 PM

Document Has Been Signed on 07/14/2026 12:55 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NIGHTINGALE CARE HOMES LLCFACILITY NUMBER:
496804107
ADMINISTRATOR/
DIRECTOR:		BERTRAND A. MENDIOLAFACILITY TYPE:
740
ADDRESS:5161 OAK MEADOW DRIVETELEPHONE:
(707) 755-3471
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 6DATE:
07/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Bertrand Mendiola (Administrator)TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived to conduct an unannounced Annual Required inspection and met with Administrator, Bertrand Mendiola. Annual fees are current.

LPA/Administrator initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Extra linens and hygiene products were available. Bathrooms have required grab bars and bath mats. Water temperature in resident bathroom read at 120.9 and 121.1 which is not within acceptable range of 105 to 120 F degrees. Toxins are located in a locked closet in one of the dining room areas. Swimming pool located in the backyard was locked with a padlock and inaccessible to residents in care. Medication is centrally stored in a locked closet near the kitchen. Fire extinguishers were last inspected December, 2025. Smoke alarms and carbon monoxide detector were tested and operational at time of inspection. Auditory alarms were functional at time of inspection. Last disaster drill conducted on 4/01/26. The facility have two days of perishable and one week of non-perishable food available. LPA observed ants during this inspection and administrator confirmed that they have an ongoing issue with ants that they are attempting to mitigate using treatments with vinegar to rid the facility of ants whenever they are observed. Required postings were observed.

Administrator will provide copies of the following by 7/28/26: (LIC500) Personnel Report, (LIC308) Designation of administrative responsibility and copy of liability certificate.
Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2026
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)
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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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NIGHTINGALE CARE HOMES LLC
FACILITY NUMBER: 496804107
VISIT DATE: 07/14/2026
NARRATIVE
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Continued from LIC809...

LPA initiated file review at approximately 10:00am. Five resident files and three staff files were reviewed. All residents have current medical assessments and care plans updated. At approximate 10:30am, LPA/administrator observed that resident (R1) who is bedridden is occupying room #1, which is not cleared by the Fire Department as a bedridden room. On 4/29/2025, the facility was granted a fire clearance for six non-ambulatory, where room #3 and 6 are cleared for bedridden clients. However, during the physical tour of the facility and records review of residents in care, it was observed R1 is occupying room #1. Licensee is operating outside the limitation of the license by accepting a bedridden resident in a non-ambulatory room. LPA/administrator had a conversation about the issue with R1 and provide the option to relocate resident to a bedroom cleared by the fire marshal for bedridden residents, but according to the administrator and LPA's observation, R1 is not bedridden, so administrator will reach out to R1's physician to obtain an updated physician's report (LIC602). During the visit, LPA spoke with R1 who expressed that they are not fully bedridden and they are in agreement to obtain an updated medical assessment. All staff have active CPR and First Aid certificates and training hours required. Administrator Certificate for Bertrand Mendiola, 6080052740 expires 12/7/27. Medication and medication records were reviewed.

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

Exit interview was conducted with Administrator and a copy of this report will be emailed due to LPA is having printer issues.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2026 12:55 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 07/14/2026 at 12:18 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: NIGHTINGALE CARE HOMES LLC
FACILITY NUMBER: 496804107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/administrator observation, records review and interview with licensee and R1 in care, the licensee did not comply with the section cited above in one out of six residents (R1) who is bedridden was properly located in a bedroom that it was cleared by the Fire Department as a bedridden room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2026
Plan of Correction
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Administrator to certify on LIC 9098 R1 has been relocated to a bedridden room or provide an updated physician report that would indicate that R1 is non-ambulatory by POC due date to clear the citation.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation, the licensee did not comply with the section cited above by hot water measured higher than 120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2026
Plan of Correction
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Administrator agreed to adjust water heater to be in compliance with regulation and will submit LIC9098 self-certification form to CCL by POC due date to clear the citation.
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:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2026 12:55 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 07/14/2026 at 12:18 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: NIGHTINGALE CARE HOMES LLC
FACILITY NUMBER: 496804107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2026

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's/administrator observation and interview the facilty failed to ensure the kitchen is clean, saitary and free of ants which poses a potental health and safty risk to residents in care. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2026
Plan of Correction
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Administrator agrees to submit a plan to ensure the facility is free of ant to CCL by POC 7/28/26.
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:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2026


LIC809 (FAS) - (06/04)
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