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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286802019
Report Date: 03/10/2025
Date Signed: 03/10/2025 11:17:10 AM

Document Has Been Signed on 03/10/2025 11:17 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:LINDA FALLS GUEST HOME 1FACILITY NUMBER:
286802019
ADMINISTRATOR/
DIRECTOR:		SACRO, NORBERTFACILITY TYPE:
740
ADDRESS:755 LINDA FALLS TERRACETELEPHONE:
(707) 963-1440
CITY:ANGWINSTATE: CAZIP CODE:
94508
CAPACITY: 6CENSUS: 6DATE:
03/10/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Lino CaramatTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility to conduct a complaint investigation. LPA met with caregiver Lino Caramat due to the Administrator being away from the facility. At approximately 8:40AM, LPA observed two residents and one staff in the main living room with jackets and sweaters on, and one resident was observed to have a dripping nose. LPA measured the ambient temperature in the facility and found it was 67 degrees. At approximately 8:45AM, LPA reviewed resident records. LPA observed there was no evidence of a medical evaluation, no Pre-Admission appraisal and no care plan in the file. LPA observed the file contained a letter sent to the responsible party on 09/15/2024, stating R1 needed a higher level of care. A similar letter was also in the file dated 09/26/2024. The letter dated 09/26/2024 appears to be a formal 60 day eviction notice. Neither of these documents were sent to Community Care Licensing at the time.

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.

This report was reviewed with Lino Caramat and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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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Document Has Been Signed on 03/10/2025 11:17 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 03/10/2025 at 10:07 AM
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: LINDA FALLS GUEST HOME 1
FACILITY NUMBER: 286802019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2025
Section Cited
CCR
87458(a)

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87458 Medical Assessment: (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.
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Licensee shall submit self certification they have read and understand Regulation 87458. Self certification shall be submitted to CCLD by 03/21/2025. Copy of regulation 87458 provided to Licensee.
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This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure R1 received a medical assessment prior to admission. This poses a potential Health, Safety or Personal rights risk to persons in care.
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Type B
03/21/2025
Section Cited
CCR87457(c)

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87457 Pre-Admission Appraisal: (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention
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Licensee shall submit self certification they have read and understand Regulation 87457. Self certification shall be submitted to CCLD by 03/21/2025. Copy of regulation 87457 provided to Licensee.
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Limitations. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not complete an evaluation of residents condition prior to admission and keep it in the file. This poses a potential Health, Safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/10/2025 11:17 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 03/10/2025 at 10:21 AM
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: LINDA FALLS GUEST HOME 1
FACILITY NUMBER: 286802019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2025
Section Cited
CCR
87303

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87303 Maintenance and Operation: (b)A comfortable temperature for residents shall be maintained at all times.(1)The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). This requirement is not met as evidenced by: Based on thermometer reading during visit,
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Licensee shall submit self certification they have read and understand Regulation 87303. Self certification shall be submitted to CCLD by 03/21/2025. Copy of regulation 87303 provided to Licensee.
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Licensee did not ensure the temperature was at least 68 degrees F. Temperature was 67 degrees. This poses a potential Health, Safety or Personal rights risk to persons in care.
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Type B
03/21/2025
Section Cited
CCR87224(f)

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87224 Eviction Procedures: (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by: Based on records reviewed, Licensee issued an eviction on 09/24/2024 to R1 and did not forward a copy to CCLD. This poses a
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Licensee shall submit self certification they have read and understand Regulation 87224. Self certification shall be submitted to CCLD by 03/21/2025. Copy of regulation 87224 provided to Licensee.
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potential Health, Safety or Personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
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