Pre-licensing visit·May 14, 2026

Licensing Program Analyst (LPA) Cuadra arrived announced to conduct a pre-licensing inspection and was greeted by Applicant, Antonio Cruz. Facility currently does not have residents in care. Once obtained, Applicant will submit proof of required liability insurance. The facility has submitted a dementia care plan. Applicant stated that they have applied for a hospice waiver for two residents, but LPA reviewed documentation provided by the Centralized Application Unit (CAB) and there was no hospice waiver on file. LPA will follow up with CAB Analyst to clarify if the facility does have a hospice waiver on file. Also, Applicant stated that they own the home, but LLC has a lease agreement as indicated in the application (LIC200). The facility received a fire clearance approval on 10/23/2025 by the Santa Rosa Fire Department for total capacity of six (6) residents which six (6) may be non-ambulatory residents in all rooms. Room #1 and #3 are approved for single occupancy rooms; Room #2 and Master bedroom #4 are cleared as shared rooms. Garage could not be used for resident's use. LPA/Applicant toured the building and grounds. The facility consists of a single story residence with a total of four bedrooms, three full bathrooms, laundry area located outside, kitchen, dining room, living room as common areas an outside sitting and garden area available for residents' use. All residents rooms are connecting to facility dinning room, living room and kitchen area through fire door. Room #2 allows access to the backyard and they have auditory alarms installed at the doors that were found operational during the visit. Confidential file storage of personnel and resident's records will be kept in the living room area locked and secured. The facility was found to be consistent with facility sketch, and at a comfortable temperature. However, Master bathroom needs one grab bar for toilet and Applicant will remove glass door and install curtains. Bathrooms located in the hallway will be designated for resident's use and it has grab bars and skid mats available. Applicant expressed that they would like to get a referral for Technical Support Program (TSP). Continues on LIC809C... Continued from LIC809... All rooms and common area had sufficient lighting, including hallways. The smoke alarms are a combination of carbon monoxide are hardwired and were observed operational during inspection. Indoor and outdoor passageways are free of obstructions and is enough to permit residents with a diagnosis of dementia wander freely and safely. Window screens are clean and in good repair. Resident rooms are needed to be furnished per regulation as follow: Shared room #2 and Master Bedroom #4 needed a bed, bedside table, dresser and chair for second occupancy. Bedroom #3 needs a bed and bedroom #4 is ready for residents to move in. Trash cans with cover lids to prevent spread of communicable disease are needed in bedrooms. First aid containing all items were observed. No surveillance cameras were observed. Garage houses incontinence care supplies and emergency supply of food and water. The facility doesn't have a generator yet. Cleaning supplies will be stored under locked kitchen sink. Sufficient supply of linens and hygiene products observed in linen closet located in the hallway. Kitchen cabinet has locks installed for knives and locked centralized medication to be inaccessible to residents in care. There are sufficient amount of dishes, utensils, cooking pots, etc. Activity calendar and supplies as well as sample of menu was observed. Water temperatures read at: 115.2 and 112.1 degrees F which is within 105-120 F degrees regulation. Fire extinguishers serviced on September 2025. Administrator certificate for administrator Antonio Gonzalez-Cruz #6071056740 expires on 6/4/2026. Facility contact information reviewed and updated landline phone number. LPA observed all required postings including the CCL Complaint Poster, Long Term Care Ombudsman Poster, Resident's Rights, and the rights to Resident and Family Councils. Applicant agrees to submit the following items for LPA review: Proof of grab bar in master bathroom for toilet. Garbage cans with tight fitting covers for all bedrooms. Shared room #2 and master bedroom #4 needed a bed, bedside table, dresser and chair for second occupancy. Applicant will remove glass door and install curtain. Bedroom #3 needs a regular bed. Each room needs a call alert system to alert staff. LPA will conduct component III and subsequent inspection after above items are submitted to confirm complete. After confirmed LPA will notify Application Unit pre-licensing inspection is complete and to proceed with licensure. Exit interview conducted with Applicant and a copy of this report was given.