496804133-8-11-2026-21-AS-CCOO-DWUS2N-20260811132949

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804133
Report Date: 08/11/2026
Date Signed: 08/11/2026 01:30:17 PM

Document Has Been Signed on 08/11/2026 01:30 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:	RINCON VALLEY ASSISTED LIVING LLC		FACILITY NUMBER:	496804133
ADMINISTRATOR/ DIRECTOR:	RAHEL GURJA		FACILITY TYPE:	740
ADDRESS:	996 ESTES DR.		TELEPHONE:	(707) 235-8007
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY: 6		CENSUS: 5	DATE:	08/11/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:59 AM
MET WITH:	Rahel Gurja, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:44 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) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Rahel Gurja arrived later. At approximately 9:30am LPA 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 drawer with sharp knives locked. Cleaning supplies located in garage inaccessible to residents in care. All bedrooms were equipped with lighting, night stand, and chest of drawers. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperatures in sinks accessible to residents in care measured at 119.9 degrees F in the main bath and 114.4 degrees F in the double occupancy room which are within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 8/10/26. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility is conducting fire drills with staff, last dated 6/23/26. Facility has two gates leading to backyard, one on each side, both of which are in disrepair. Additionally, front deck has one board in disrepair. Board on back deck, located right after ramp from sliding glass door, deeply bows when pressure is applied. Admin advised facility will fix immediately. Backyard also has dried brush and dried bushes in backyard in back on right hand side across from the fig tree that could present as a fire hazard. LPA and Admin discussed removing the dried brush as well as chairs that have black and green fuzz on them. LPA and Admin discussed disposing of the old commode chair that is present in backyard. Continued on 809C...

Victoria Bertozzi
Christi Coppo
	DATE: 08/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026

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: RINCON VALLEY ASSISTED LIVING LLC	FACILITY NUMBER: 496804133
	VISIT DATE: 08/11/2026

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Continued from 809....

At approximately 11:00am LPA conducted a review of five [5] resident records. Facility has two (2) residents that are bedridden. Both residents are on hospice. Admin produced copies of emails sent to fire dept notifying them of resident with bedridden status. LPA did not observe any activities for bedridden resident (R1). LPA and licensee discussed activities at length at 2025 annual. Facility did not have any activities for residents. LPA and licensee discussed adding activities, especially for residents that are bedridden. During today's visit, LPA observed lack of TV, radio, or anything in R1's room that could provide sensory stimulation. LPA discussed with Admin that LPA discussed with licensee at 2025 annual facility having the same issue. Admin had caregiver immediately hook up a TV in resident's room. LPA stressed to Admin that activities that provide sensory stimulation must be maintained available as required by regulation 87219.

LPA discussed with Admin resident appraisals. Currently, appraisals are completed by residents' responsible parties. LPA discussed with Admin completing the appraisals herself in addition to those completed by residents' responsible parties. LPA discussed with Admin that it is good practice to complete the appraisal herself, this will allow her to determine if a potential resident is compatible with other residents and/or if facility staff will be able to meet the care needs of resident, among other valuable uses. LPA advised Admin that LPA has this same discussion with licensee at 2025 annual. At approximately 12:00pm LPA conducted review of three [3] staff records. LPA discussed with Admin if facility admits bedridden residents, training for bedridden care must be completed by staff as required by regulation 87606(f)(3). LPA discussed with Admin Health and Safety Code 1569.69 and advised of specific subject matters required for all staff doing medication administration. LPA discussed with Admin ensuring documentation for shadowing and hands-on training is completed.

At approximately 2:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. LPA went over the requirement to keep a PRN MAR/log that meets the requirements of regulation 87465. LPA advised that if a resident has a prescription for a regular medication and PRN medication of the same name but of different doses, such as Tylenol, be sure to follow the instruction on each bubble pack. Otherwise, it could look like the medication count is off.

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 and Liability Insurance. No deficiencies cited. 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: 08/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026

LIC809 (FAS) - (06/04)

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