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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804373
Report Date: 04/03/2026
Date Signed: 04/03/2026 12:01:47 PM

Document Has Been Signed on 04/03/2026 12:01 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:AROHA MEMORY CAREFACILITY NUMBER:
496804373
ADMINISTRATOR/
DIRECTOR:		KALRA, RAJESHFACILITY TYPE:
740
ADDRESS:6575 OAKMONT DRTELEPHONE:
(925) 683-1975
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 27CENSUS: 7DATE:
04/03/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:46 AM
MET WITH:Joe Hansen, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
12:16 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct a Case Management. LPA met with Executive Director (ED), Joe Hansen. Licensee was available by phone.

On 3/9/26 CCL received an Incident Report from facility indicating a medication error had occurred for residents (R1, R2, R3, and R4). On 3/2/26 the scheduled medications for R1, R2, R3, and R4 were not administered (deficiency cited, see 809D). The Health and Wellness Director (HWD) was the staff member responsible on shift to administer medications. However, the HWD became ill during working hours and was unable to complete the medication pass that shift. Unfortunately, HWD did not communicate to upper management that they were not able to complete the medication pass for that shift. As a result, the evening medications for R1, R2, R3, and R4 were missed. According to the Incident Report submitted by licensee, none of the four [4] residents experienced any injuries, adverse reactions, or negative behaviors as a result of the missed medication pass.

Due to this medication error, licensee conducted an audit of medication and medication records. The audit revealed another error pertaining to resident (R4). R4 was prescribed 5mg of Apixaban to be administered twice daily. However, medication records show that R4 only received the 5mg of Apixaban once daily. The Apixaban was prescribed on 2/18/26 and the correct milligram dose began being administered 3/4/26.

Per licensee, all affected residents (R1, R2, R3, and R4) of medication errors were reviewed and monitored for any potential adverse effects. Licensee reported no injuries or negative outcomes were observed or noted. During visit, LPA reviewed charting notes of R1, R2, R3, and R4. Charting notes identify daily activity

Continued on 809C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2026
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: AROHA MEMORY CARE
FACILITY NUMBER: 496804373
VISIT DATE: 04/03/2026
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Continued from 809...

and help with ADLs, but did not specifically note staff checking for adverse reactions. However, LPA did not observe any negative outcomes or side effects noted pertaining to ADLs. Per licensee, resident families were all notified as well as primary care physicians. LPA reviewed charting notes in ALICE noting primary care physician and responsible parties being notified but ED could not produce an email or fax showing notification occurred. LPA and ED discussed the importance of ensuring the notifications are documented in such a way as to produce a written record.

As a result of the errors and review of the audit, licensee terminated the employment of the HWD. Additionally, a staff meeting was held to discuss medication management and administration with all staff responsible for medication administration. LPA reviewed proof of training for all staff responsible for medication administration. LPA found all required documentation present. LPA and ED discussed developing a shift change-over acknowledgment/notes sheet.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with ED 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: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/03/2026 12:01 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/03/2026 at 09:49 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: AROHA MEMORY CARE
FACILITY NUMBER: 496804373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2026
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility…and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self administered medications as needed.
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Facility to submit plan to conduct training on medication management including ordering, checking-in medications, and maintaining inventory by plan of correction due date. Recognizing medications changes will also be covered. Facility to conduct training by no later than 4/17/26. Training to be conducted with all staff administering medication
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This requirement is not met as evidenced by: Based on LPA record review, the licensee did not comply with the section cited above in that R1, R2, R3, and R4 did not receive their medication which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2026


LIC809 (FAS) - (06/04)
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