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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804156
Report Date: 02/19/2025
Date Signed: 02/19/2025 03:26:21 PM

Document Has Been Signed on 02/19/2025 03:26 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:PENNGROVE GARDENSFACILITY NUMBER:
496804156
ADMINISTRATOR/
DIRECTOR:		CARDENAS, CRISANTEFACILITY TYPE:
740
ADDRESS:1895 ALAN DRIVETELEPHONE:
(707) 327-6968
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY: 8CENSUS: 8DATE:
02/19/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Cris Cardenas, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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At approximately 1:55PM, Licensing Program Analysts (LPAs) Loera and Stevenson arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Cris Cardenas. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL) on 01/30/2025.

The incident report states that Resident 1 (R1) fell from their bed. Staff immediately called 911 and R1 was transported to the hospital and then transported to a rehab center. Per conversation with Administrator and document review, R1s responsible party discharged R1 against medical advice from the rehab center and was returned to facility on 02/01/2025. Per conversation with Administrator, facility has instituted a fall prevention plan with a motion detector in front R1s bed and has night time staff posted outside of R1s bedroom for supervision. LPAs requested for facility to send in writing of updated care plan. Per review of R1s diagnosis, R1 has a history of falls.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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