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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804291
Report Date: 04/01/2026
Date Signed: 04/01/2026 04:18:20 PM

Document Has Been Signed on 04/01/2026 04:18 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:VILLA GARDENSFACILITY NUMBER:
216804291
ADMINISTRATOR/
DIRECTOR:		CAMACLANG, ALBERTINAFACILITY TYPE:
740
ADDRESS:25 VILLA AVENUETELEPHONE:
(650) 722-3521
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 12CENSUS: 8DATE:
04/01/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Staff Member, Nancy Mckee and Licensee, Tina CamaclangTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1 Year Required visit and met with Staff Member, Nancy McKee. Licensee, Tina Camaclang, arrived during visit at approximately 10:40AM. Facility provides care and assistance to older adults and has a dementia care program on file. Facility has an approved fire clearance for a total capacity of 12 non-ambulatory residents. Upon arrival, LPA was informed that there were currently 8 residents in care and 3 staff members on-site.

At approximately 9:10AM, LPA reviewed the Facility's Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPA conducted a walk-through of the facility and made the following observations: Per facility sketch, facility consists of 8 resident rooms, a staff break room, and common areas. Facility has a separate building for laundry and extra storage. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has an Infection Control Plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins and other hazards were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for all facility sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit.

During walkthrough, LPA observed the following:
  • Multiple instances of food being unlabelled in facility fridge
  • Facility freezer in need of cleaning - observed frozen liquid and food particles at the bottom of freezer drawer.
    • During visit, LPA observed facility staff put dates on unlabelled foods and clean the freezer drawer of liquid and food particles.
Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2026
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.

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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: VILLA GARDENS
FACILITY NUMBER: 216804291
VISIT DATE: 04/01/2026
NARRATIVE
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Continued from LIC809
  • Prepoured noon medications for two residents observed on kitchen counter and additional prepoured bedtime medication found in locked medication cabinet for multiple residents
  • LPA observed that a kitchen cabinet door was not attached leaving the facility pots and pans exposed, and a resident's toilet lid and seat was not fastened to the toilet
  • Resident bathroom wastebins did not have lids on them
  • LPA observed that staff break room was being used as additional storage and had multiple bags and other boxed items
  • Facility did not have emergency water supply on-site

LPA observed that facility's last documented emergency/disaster drill was conducted December 2025. Per Licensee and facility staff, they had an emergency drill in March 2026 but were unable to provide documented proof of drill. Facility's emergency disaster plan was last reviewed and updated 12/2025. Facility's smoke and carbon monoxide detectors were tested and operational. LPA observed that facility's fire extinguisher was newly purchased per receipt stating 03/2026.

LPA reviewed 4 staff files. Staff Files were all found to have current First Aid and CPR certification. 2 of 4 staff files were shown to not have a health screening or negative TB test on file. 1 of 4 staff files showed that Staff Member 4 (S4) was hired by the facility on 10/01/2025 but had their health screening and TB test done on 12/12/2024. Per Title 22 Regulations, a health screening shall be completed no longer than 6 months prior to their employment. Administrator's Certificate for Albertina Camaclang (7002848740) was current with an expiration date of 02/16/2028.

LPA reviewed 4 resident files. Resident files had updated assessments and reappraisals. 2 of 4 residents had missing consent forms. 1 of 4 residents did not have their appraisal signed. During walkthrough, LPA observed that Resident 1 (R1) had full bed rails. Review of R1's file showed that R1 has been receiving hospice services since 2025 but did not have a care plan or hospice care plan on file indicating if there was an order or specified need for their full bed rails.

LPA conducted a spot audit of 3 Resident medications. LPA observed the following errors:
  • Facility was not completely filling out medication expiration dates and was only documenting month and year instead of month, day, and year as shown on the pharmacy label.
  • Error in filling out expiration and fill dates per pharmacy label

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026
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: VILLA GARDENS
FACILITY NUMBER: 216804291
VISIT DATE: 04/01/2026
NARRATIVE
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Continued from LIC809C
  • Clearlax medication was labelled as "Over the Counter" or OTC, when it had a pharmacy label for the facility to document on the LIC622 or Centrally Stored Medication and Destruction Record
  • Facility had some resident medication that was not logged as required.

LPA is requesting the following documents to update facility file:
  • Designation of Facility Responsibility (LIC308)
  • Updated Personnel Report (LIC500)
  • Updated Liability Insurance

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), LIC9102 (Technical Advisories/Violations), Plan of Corrections, and Appeal Rights discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/01/2026 04:18 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 04/01/2026 at 03:20 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VILLA GARDENS
FACILITY NUMBER: 216804291

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Licensee did not comply with the section cited above. 2 of 4 staff members did not have proof of health screening or negative TB test. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2026
Plan of Correction
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Licensee to submit self-certification stating that identified staff members will obtain proof of health screening and negative TB test. Self Certification to be submitted by POC due date of 04/02/2026. Proof of documents to be submitted by POC due date of 04/13/2026.

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:
Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2026


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 04/01/2026 04:18 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 04/01/2026 at 03:20 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VILLA GARDENS
FACILITY NUMBER: 216804291

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above. Multiple instances of unlabelled foods were observed. LPA also observed that facility freezer drawer had frozen liquid and food particles. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2026
Plan of Correction
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Licensee to conduct in-service training on proper storage of food, including labelling and ensuring food storage areas are clean. Training to include the following: Date, Topic, Job Role, Staff Names, and Signatures. Training to be submitted to CCL for review and approval by POC due date of 04/13/2026.
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and observations made, Licensee did not comply with the section cited above and did not ensure that resident medications were centrally stored and recorded on the LIC622 as required.This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2026
Plan of Correction
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Licensee to conduct in-service training on properly centrally storing medication. Training to include the following: Date, Topic, Job Role, Staff Names, and Signatures. Training to be submitted to CCL for review and approval by POC due date of 04/13/2026.
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:
Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2026


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 04/01/2026 04:18 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 04/01/2026 at 03:20 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VILLA GARDENS
FACILITY NUMBER: 216804291

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above. Multiple medications were observed to be prepoured for noon and bedtime medication. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2026
Plan of Correction
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Licensee to conduct in-service training on pre-pouring expectations. Training to include the following: Date, Topic, Job Role, Staff Names, and Signatures. Training to be submitted to CCL for review and approval by POC due date of 04/13/2026.
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above. Licensee did not ensure that there was enough water on-site in the event facility had to shelter-in-place for 72 hours. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2026
Plan of Correction
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Licensee to submit receipts and/or photos of obtained water to meet emergency disaster requirements by POC due date of 04/13/2026.
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:
Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2026


LIC809 (FAS) - (06/04)
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