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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804156
Report Date: 08/05/2025
Date Signed: 08/05/2025 03:33:00 PM

Document Has Been Signed on 08/05/2025 03:33 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: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:
08/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Crisante Cardenas, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 08/26/2024, Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and met with Administrator, Chris Cardenas. Facility is 2 story with all 8 resident bedrooms on first floor. Facility approved/cleared for 8 non-ambulatory, and three (3) bedridden, with a hospice waiver approved for three (3). There are currently eight (8) residents in care, (7) seven with dementia diagnosis and two (2) on Hospice.

At approximately 11:50am, LPA and Administrator toured the building and grounds. All door alarm systems were observed to be in functioning order. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

All rooms were equipped with lighting, nightstand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care measured between 108.1 degrees F and 113.9 degrees F in 8 sinks, within Title 22 range of 105 to 120 degrees F. All shower floors have slip-resistant mats as required by Title 22 regulations. Fire extinguishers were last inspected 4/1/2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose a threat if available to residents were located in the carport, laundry room and next to the kitchen sink and found to be secured. LPA conducted spot medication count and found all prescription medication to be centrally stored and inaccessible to residents in care.
Continue on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2025
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: PENNGROVE GARDENS
FACILITY NUMBER: 496804156
VISIT DATE: 08/05/2025
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Continue from LIC809

At approximately 1:00 pm, LPA conducted a review of five (5) resident records. Reviewed files had the required documentation.

At approximately 1:45 pm, LPA conducted review of five (5) staff records/training. Upon a review of staff records, LPA found all staff were background cleared by DOJ and associated to facility, as well, have required initial training & annual training as well have current 1st Aid & CPR certification on file. Administrator certificate for Crisante Cardenas # 7007975740 expires 3/24/2027. Facility conducts quarterly disaster drills, in different shifts, with the last conducted 6/11/2025. Facility has emergency lighting system in hallways connected to built in generator should power go out. Facility has weekly guitar and piano players entertain residents along with every other day activity director conducts exercises/stretch & flex’s & dancing.

No deficiencies observed during today’s inspection; no citations given.

Updated copies of the following documents were requested and submitted to LPA or CCL by 8/22/2025:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC309- Administrative Organization
Liability Insurance
Administrator Certification
(emergency/disaster plan and infection control plain - if any changes have been made)

Exit interview conducted with Administrator and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC809 (FAS) - (06/04)
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