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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804141
Report Date: 05/13/2025
Date Signed: 05/13/2025 11:38:30 AM

Document Has Been Signed on 05/13/2025 11:38 AM - 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:MILLS MANORFACILITY NUMBER:
496804141
ADMINISTRATOR/
DIRECTOR:		KUEHNHACKL, ANTONFACILITY TYPE:
735
ADDRESS:9790 OCONNELL RDTELEPHONE:
(707) 824-8403
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 6CENSUS: 3DATE:
05/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Anton Kuehnhackl (Licensee/Administrator)TIME VISIT/
INSPECTION COMPLETED:
11:53 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee, Anton Kuehnhackl. Annual fees are current.

LPA/Licensee initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstruction. Client bedrooms were furnished per regulation. Water temperatures in bathrooms ranged from 115.3 and 113.4 F which is within regulation. Extra linens and hygiene products were available. At least two days of perishable and one week of non-perishable food was available. Toxins were inspected and are locked in a cabinet in the laundry room. Medications are centrally stored in a locked closet in the dining room. Fire extinguisher was last inspected February 2025. Smoke detectors throughout the facility and carbon monoxide detector were tested and operational. Facility has smoke detectors and sprinklers. Fire panel was last inspected 11/6/23. Most recent disaster drill was conducted January 12, 2025. The facility does not handle cash resources. Required postings were observed.

LPA initiated file review at approximately 9:00am. Two staff and three client files were reviewed. Residents have medical assessments and individualized care plans. Staff records indicated that CPR/1st aid and staff have received required annual training hours. Administrator Certificate for Rudolf A. Kuehnhackl, 7015460735 expires 03/13/26. Contact information was reviewed.
Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2025
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MILLS MANOR
FACILITY NUMBER: 496804141
VISIT DATE: 05/13/2025
NARRATIVE
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Continued from LIC809...

During file review, LPA/Administrator observed that client (C1) has a non-ambulatory status in their physician's report, but C1 was observed walking around the facility without any ambulation challenge, so LPA inquired with Administrator and it was determined that this discrepancy needs to be addressed with their physician to change the ambulatory status. Approved Fire Clearance dated 5/30/23 for the facility allowing two non-ambulatory clients.

At approximate 10:00am, medication and their records were reviewed. Three out of three C1's prescribed medications allergy medicine (diphenhydramine HCL 25 mg), melatonin 10mg and chewable vitamin C 250 mg; One out of three C2's medications sertraline HCL 25 mg; five out seven C3's medications quetiapine 100 mg, famotidine 20mg, trazodone 50mg, aripiprazole 2mg, levothyroxine 88mcg were not documented in the centrally store medication log. During file review, LPA/Licensee observed that C1's after visit summary dated 2/7/25 revealed that C1 had a medication change to discontinue taking ascorbic acid 250 mg tabs (vitamin C). However, the facility staff did not discontinued the medication as instructed by C1's physician. According to records review, C1's allergy medication was prescribed 10/28/20 before the change of ownership, but no documentation was found on file that provided evidence that prescription is still active in current medication orders list (technical violation issued). Licensee agreed to review, obtain and update all resident's medications with properly physician's orders and maintain centrally stored medication logs as stated per regulation.

Licensee agreed to submit the following documents by 5/19/25: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency disaster plan (if there are any changes LIC610E) and surety bond.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency &/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Licensee and copy of report was given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2025 11:38 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 05/13/2025 at 11:17 AM
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: MILLS MANOR
FACILITY NUMBER: 496804141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above when C1 had a medication change to discontinue vitamin C and facility did not discontinued medication, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2025
Plan of Correction
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Licensee agrees to discontinue vitamin C medication for C1 and will submit a self-certification form LIC9098 ensuring that all staff have received additional medication training by POC due date to clear the citation.
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: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2025 11:38 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 05/13/2025 at 11:17 AM
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: MILLS MANOR
FACILITY NUMBER: 496804141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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's Licensee observation, interview and record review)], the licensee did not comply with the section cited above in 3 out of 3 C1's medication; 1 out of 3 C2's medication and 5 out of 7 C3's medications were not entered into CSMDR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2025
Plan of Correction
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Licensee to ensure clients' records of centrally stored prescription medications and PRN are kept current and up to date. Licensee to updated CSMR for all clients at the facility and submit a LIC 9098 self certification that all CSMRs for all clients have been updated and are current to CCL by POC date of 5/19/25.
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: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
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