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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280100627
Report Date: 04/07/2026
Date Signed: 04/07/2026 05:31:11 PM

Document Has Been Signed on 04/07/2026 05:31 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:PINER'S GUEST HOMEFACILITY NUMBER:
280100627
ADMINISTRATOR/
DIRECTOR:		PINER, GARYFACILITY TYPE:
740
ADDRESS:1800 PUEBLO AVENUETELEPHONE:
(707) 255-3461
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 28CENSUS: 13DATE:
04/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Deirdre Villante, SupervisorTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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At approximately 11:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Deirdre Villante, Supervisor. Facility is a Residential Care Facility for the Elderly (RCFE) with thirteen (13) residents in care. Facility serves assisted living residents, has a Hospice waiver for 2, and is approved for all non-ambulatory residents.

At approximately 12:00 PM, LPA initiated a tour of the facility with Supervisor and observed the following: Facility is a one story building, was a comfortable temperature, and passageways were free from obstructions. LPA observed call bells in each resident bedroom and staff responded timely when activated. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Closets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There are outdoor shaded seating areas for activities. LPA observed residents engaged in activities in common areas. Facility has internet service and Supervisor agrees to have an internet access device designated for resident use as required per regulation.

Facility's last fire inspection was conducted 03/2026. Fire extinguishers were observed fully charged and were last inspected 01/2026. Emergency Disaster Plan was reviewed and updated 10/2025. Facility conducts quarterly disaster drills but the most recent drill was conducted 06/2025.

Continued on LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2026
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: PINER'S GUEST HOME
FACILITY NUMBER: 280100627
VISIT DATE: 04/07/2026
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Continued from LIC809C...

Supervisor agrees to conduct a drill immediately to bring the facility back into compliance with regulation and understands that drills shall be conducted no less than quarterly.

At approximately 1:00 PM, LPA conducted file review of five (5) staff files. Three (3) of five (5) staff files reviewed were observed missing proof of current first aid training as required per regulation, (see LIC809D). Four (4) of five (5) staff files reviewed were also observed missing proof of all of the required annual training and annual medication training hours, (see LIC809D).

At approximately 3:30 PM, LPA reviewed five (5) resident files. Supervisor agrees to ensure that all resident files contain updated annual appraisal needs and services plans as required to ensure compliance with regulation. All resident files reviewed contained the remaining required documentation.

Facility assists with coordinating medical and dental appointments as well as third party transportation services to and from appointments when residents have the need. Medications and medication records were inspected and the logs were observed maintained in compliance with regulation. Facility does not handle P&I cash resources.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • Proof of current liability insurance in the required amounts
  • Current Fire Inspection Report
  • LIC500 - Personnel Report (updated)

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and/or The Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.


Exit interview conducted with Supervisor and appeal of rights provided. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/07/2026 05:31 PM - It Cannot Be Edited


Created By: Julie Florio On 04/07/2026 at 04:38 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: PINER'S GUEST HOME
FACILITY NUMBER: 280100627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Staff training; legislative findings; contents ยง1569.625(b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 5 staff files reviewed observed missing proof of all of the required annual training and annual medication training hours which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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LIcensee to submit sefl-certification that all staff have completed all of the required training hours to CCLD by POC due date of 05/08/2026.
Type B
Section Cited
CCR
87411(c)(1)

Personnel Requirements - General 87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 staff files reviewed were obserevd missing proof of valid first aid training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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Licensee agrees to submit a self-certification that all staff have current first aid certifications to CCLD by POC due date 05/08/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2026


LIC809 (FAS) - (06/04)
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