<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200855
Report Date: 03/11/2026
Date Signed: 03/11/2026 05:37:05 PM

Document Has Been Signed on 03/11/2026 05:37 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:TODOS SANTOS ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
079200855
ADMINISTRATOR/
DIRECTOR:		CLAWSON, DAVID JFACILITY TYPE:
740
ADDRESS:1081 MOHR LNTELEPHONE:
(925) 798-3900
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 160CENSUS: 151DATE:
03/11/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:00 PM
MET WITH:David Clawson, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
06:00 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
On 03/11/2026 at 5:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Executive Director, David Clawson, and explained the purpose of the visit.

While conducting complaint investigation 15-AS-20251118152637 on 03/11/2026, LPA conducted record review and interviews. Based on record review, interviews, and documents obtained during the investigation, LPA determined the following:

1. Resident (R1)’s financial records for 2022 were not maintained at the facility. On 03/04/2026, Staff (S1) stated, “Our business took over operations on March 1, 2025. We do not have financial records for the information you requested back on 9/1/22.”

2. Community Care Licensing Division (CCLD) was not notified of fall incidents involving R1. Facility records indicate R1 sustained a fall on 03/17/2025, and four (4) additional falls on 07/10/2025 at approximately 3:15 AM, 4:30 AM, 4:45 AM, and 5:15 AM. Records further indicate that on 04/06/2025 a call pendant alert was activated with a documented response time of 161.9 minutes, after which R1 was sent out for medical attention. On 03/05/2026, Staff (S2) stated via email, “Unfortunately, we wouldn’t do a LIC 624 when a resident is not sent out. But we created an incident report documenting the incident and the resident refusing to be sent out.”

LIC809-C Continued...
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
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)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TODOS SANTOS ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 079200855
VISIT DATE: 03/11/2026
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
26
27
28
29
30
31
32
LIC809-C (Page 2)

3. R1’s Appraisal Needs and Services Plan was not updated to address repeated fall incidents.

4. R1’s records were not provided following a written request from the resident/resident’s representative.

These deficiencies were observed and cited in accordance with the California Code of Regulations, Title 22 (see LIC 809D). Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted. A copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/11/2026 05:37 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 03/11/2026 at 04:41 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TODOS SANTOS ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 079200855

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2026
Section Cited
CCR
87506(d)

1
2
3
4
5
6
7
87506(d) Resident Records
(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee shall ensure that R1’s records including but not limited to financial, billing statements from admission in 2022 are retrieved and maintained in the facility files.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above in by not ensuring that complete and former resident records were maintained and available for review as required. Specifically, the financial records for R1 from the year 2022 were not available during the visit on 11/19/25 and 03/11/26. In which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
The Executive Director shall submit proof of record retrieval (copies or verification of access) to the Department by due date.
Type B
03/25/2026
Section Cited
CCR87211(a)(1)

1
2
3
4
5
6
7
87211(a)(1) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.


This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to conduct In-Service training will a staff, on all shifts in assisted living and memeory care and will send sign in sheet to CCLD by POC due date.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above in by not reporting the fall incident with R1 to Licensing which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 03/11/2026 05:37 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 03/11/2026 at 04:48 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TODOS SANTOS ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 079200855

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2026
Section Cited
CCR
87463(a)(b)

1
2
3
4
5
6
7
87463 Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition…(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to conduct In-Service training with all 3 clinical leaders and including Administrator. Administrator will send sign-in sheet to CCLD by POC due date.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above in by not updating reappraisals for R1 with the frequent falls which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
03/25/2026
Section Cited
CCR87468.2(a)(19)(2)

1
2
3
4
5
6
7
87468.2 (a)(19) Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to obtain records and send to R1. Administrator will advise CCLD via email when records have been submitted to resident.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above in by not giving R1 and/or R1's representative copies of R1's records as requested which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/11/2026 05:37 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 03/11/2026 at 04:53 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TODOS SANTOS ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 079200855

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2026
Section Cited
CCR
87465(g)

1
2
3
4
5
6
7
87465(g) Incidental Medical and Dental Care
(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will conduct In-Service training with all staff on all shifts in assisted living and memory care and will send a copy of sign in sheet to CCLD by POC due date.
8
9
10
11
12
13
14
Based on record review and interviews, the licensee did not comply with section above by not activating 9-1-1 if an injury or other circumstance which poses a potential health and safety risk to the persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6