Routine inspection·December 4, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by licensee Rosa Soto, Administrator Cert# 7001845740 expires 8/29/27. At approximately 9:30am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen drawer with sharp knives locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. All upstairs resident bathrooms had required bath mats and grab bars. Downstairs resident shower is rarely used by resident; however it needs a grab bar installed. Facility maintenance will install a grab bar immediately. Water temperature in sink accessible to residents in care measured at 109.7 degrees F in the kitchen, 108.7 degrees F in the downstairs hallway bathroom, and 105.6 in room #1 upstairs, all of which are within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 4/22/25. Smoke/Carbon Monoxide detectors and sprinklers located throughout the facility are hard wired and last serviced by Santa Rosa Fire Equipment Inc on 4/21/25. Facility is now documenting their disaster drills, LPA and licensee discussed making sure they document them every quarter. Facility has resident bedrooms located upstairs on the second floor. There is a door in the upstairs hallway that leads outside and down a steep stair case; facility has door alarm present and two locks. Facility has an evacuation chair but it is not located near the stairwell. Facility maintenance moved Continued on 809C... Continued from 809... the stairwell chair while LPA present, chair is now located immediately near the stairwell. Facility has an elevator, permit issued by the State of California, expiration date 2/2026. Facility has a backup generator for use during a power outage. At approximately 11:30am LPA conducted a review of six (6) of six (6) resident records. No residents currently on hospice. All required documentation present. No deficiencies cited. At approximately 1:00pm LPA conducted review of five (5) staff records. LPA discussed training materials with licensee last year and facility agreed to either update training materials or choose an approved vendor for training. Training materials used for training are videos from Community Care Options dated 2011. LPA discussed with licensee the reasons for not updating their materials as discussed last year or switching to an approved vendor. Licensee advised LPA that she will now use an approved vendor going forward, licensee advised she will use Community Care Options (CCO). LPA advised should she change her mind and choose to conduct her training herself please submit updated materials for CCL review. However, to clear deficiency issued today, licensee has stated she will use CCO. Staff have all received eight (8) hours of dementia and medication training as well as four (4) hours of hospice training. LPA and licensee discussed ensuring all staff receive training in compliance with Health and Safety Code 1569.625, which includes other required topics such as restricted conditions and postural supports. LPA also discussed with licensee that all new employees must complete 40 hours of training and existing staff must complete at least 20 hours annually ( deficiency cited, see 809D ). LPA discussed with licensee regulation 87411(f) requiring all staff to have a Health Screen completed before employment. LPA discussed with licensee that the required Health Screens must be completed by a physician not more than six (6) months prior to or seven (7) days after employment. S2, S3, and S5 need to have a Health Screen ( deficiency cited, see 809D ). Continued on 809C(2)... Continued from 809C... At approximately 3:00pm LPA and licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. LPA discussed and reviewed with the licensee requirements for PRN MARs. LPA discussed with licensee regulation 87303(i)(2), the requirement to have a signal system that is operation for all residents. LPA discussed with licensee that the system must operate from each resident's living unit, transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff, and identify the specific resident living unit. Licensee will purchase a signal system that is in compliance with regulation. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given .