496804372-7-21-2026-21-AS-CCOO-DW7SG8-20260721135130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804372
Report Date: 07/21/2026
Date Signed: 07/21/2026 01:51:42 PM

Document Has Been Signed on 07/21/2026 01:51 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:	BRUSH CREEK ASSISTED LIVING		FACILITY NUMBER:	496804372
ADMINISTRATOR/ DIRECTOR:	ARROYO, SAVANNAH		FACILITY TYPE:	740
ADDRESS:	920 ACACIA LANE		TELEPHONE:	(916) 690-0366
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY: 15		CENSUS: 0	DATE:	07/21/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Savannah Arroyo, applicant		TIME VISIT/ INSPECTION COMPLETED:	02:06 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 announced to conduct a pre-licensing inspection and was greeted by applicant Savannah Arroyo. Facility currently does not have residents in care. Facility has fire clearance for fifteen [15] ambulatory residents. Applicant will submit proof of required liability insurance. At approximately 9:30am LPA and Applicant toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA advised need for emergency supply of non-perishable food and water. Kitchen has door with locking capability. Kitchen range has induction heating. LPA advised of food storage regulation 87309(a)(1) which requires all toxins and disinfectants, and cleaning solutions to be stored separately from food and food supplies. Facility is a single story building with nine [9] bedrooms: three (3) are single occupancy and six (6) are double occupancy. All bedrooms had bed, nightstand, and chest of drawers present. All rooms but one need a chair added. LPA advised of regulation 87303(a)(3)(B) which also states that each room should have a lamp or light sufficient for reading. Window screens need to be present in all rooms. Additionally, all facility doors leading to the exterior need to have an auditory alert device added to monitor exits on exterior doors and perimeter fence gates, applicant will add before licensure is granted. Rooms #8 and #9 will be dedicated as a live-in staff room, until facility is at full capacity. Facility also has activity area and an additional dedicated activity room, laundry room, kitchen, office area, and dining area. Facility has five (5) full bathrooms and one (1) half bath. All bathrooms are shared. LPA advised applicant of regulation 87303(a)(3)(C) which states the use of common wash cloths and towels is prohibited. Some of the bathrooms have the required grab bars, others do not. Applicant will add all required grab bars to showers and toilets before licensure is granted. Applicant showed LPA brand new non-skid mats that will be placed in bathrooms upon resident occupancy. Facility has automatic sensor Continued on 809C...

Victoria Bertozzi
Christi Coppo
	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

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: BRUSH CREEK ASSISTED LIVING	FACILITY NUMBER: 496804372
	VISIT DATE: 07/21/2026

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faucets present in bathrooms, which do not have designated cold and hot water options. LPA discussed with applicant the need for water to be at a temperature between 105 degrees F and 120 degrees F. Applicant will adjust faucet settings so that when activated, water dispenses at a temperature within regulation 87303(e)(2). LPA did get one water reading in kitchen of 129.8 degrees F. LPA advised temperatures which are within regulation fall within 105 & 120 degrees F. Water temperature readings must be within regulation before licensure. Facility utilizes well water, but applicant was advised per their CAB analyst that a bacterial analysis is not required because the resident will be provided filtered water for drinking. However, LPA discussed applicant sending analysis for facility file.

Facility has an east and west corridor. Facility has two (2) designated fire exits, one off each corridor. LPA observed emergency shut off valves for water and gas.

LPA discussed with applicant identified items which could present as possible safety hazards to residents. Facility has small step in the west corridor that could pose as tripping hazard. Applicant advised LPA they will look in to creating a graduated slope to minimize risk. Small step or lip also present in entrance to bathrooms #1 and #2, applicant will add something to remove tripping hazard. Facility has gas line pipe exposed in the west corridor, nail head exposed. Applicant will add cover to gas line pipe before licensure.

Facility has large outside area for residents to enjoy. However, fence on has minor holes and one board in disrepair. Applicant will fix fence, repairs very minor so repair not required before licensure. Facility has two designated shaded area for residents to utilize and a wrap around eave.

LPA observed fire/smoke alarms to be hardwired and operational. It was not clear if carbon monoxide detectors were part of the hardwired fire/smoke alarm system. Applicant will submit proof of combo system or add carbon monoxide detectors before licensure.

Applicant advised LPA that they will be adding surveillance cameras to the facility via RIng. LPA advised there is no regulation for video surveillance. However, LPA advised that video cannot include audio and must be disclosed to all residents and responsible parties. Additionally, LPA advised that video is only permitted in common areas and cannot be used in lieu of adequate staffing.

Continued on 809C(2)...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

LIC809 (FAS) - (06/04)

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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: BRUSH CREEK ASSISTED LIVING	FACILITY NUMBER: 496804372
	VISIT DATE: 07/21/2026

NARRATIVE

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Four (4) extinguishers present and last serviced on 10/7/25. First aid kit present with all required items. LPA observed all required postings and posters present. Night lights in hallway present.

LPA reviewed LIC601E and Infection Control Plan. Applicant states that most recent LIC610E submitted to CAB analyst has Temporary Shelter Locations listed. Applicant will forward updated LIC610E if LPA not able to get updated page from CAB analyst.

Items to be added as residents fill vacant rooms: lamp, chair, emergency water and food supply, and enough food for each resident such that there is enough for a 2 day supply of perishable and a 7 day supply of non-persihable food.

Items required to be repaired/addressed before licensure:

All bathrooms have grab bars present for showers and toilets
Water temperature readings within regulation
All facility doors leading to the exterior need to have an auditory alert device present
Proof of combo fire alarm/carbon monoxide system or add carbon monoxide detectors

Applicant to notify CCL once all repairs complete. LPA will then return to inspect the above items before recommending applicant for licensure.

Comp III reviewed and completed. Exit interview conducted with applicant and a copy of this report given.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

LIC809 (FAS) - (06/04)

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