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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803969
Report Date: 06/17/2025
Date Signed: 06/18/2025 02:16:11 PM

Document Has Been Signed on 06/18/2025 02:16 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:ANNIE'S FAMILY HOME CARE OF CALISTOGAFACILITY NUMBER:
286803969
ADMINISTRATOR/
DIRECTOR:		CARISMA PATTERSONFACILITY TYPE:
740
ADDRESS:1119 MITZI DR.TELEPHONE:
(707) 341-3123
CITY:CALISTOGASTATE: CAZIP CODE:
94515
CAPACITY: 6CENSUS: 3DATE:
06/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Carisma Patterson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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At approximately 10:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Susanna Villasenor, Licensee. Carisma Patterson, Administrator was contacted via telephone and arrived at approximately 11:00 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with three (3) residents in care. All residents were present during today's inspection. Facility has a hospice waiver for six (6), bedridden waiver for one (1), and is approved for all non-ambulatory residents.

At approximately 11:30 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. LPA observed the required postings in the facility's entryway. 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 clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were observed 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 is a shaded seating area in the backyard with outdoor space for gardening and activities. LPA inspected two locked sheds in the backyard which contained holiday decor, care equipment, PPE, tools, chemicals, and a back up generator for emergency preparedness.

LPA observed residents watching TV or working on puzzles in the common area of the facility.
Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2025
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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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: ANNIE'S FAMILY HOME CARE OF CALISTOGA
FACILITY NUMBER: 286803969
VISIT DATE: 06/17/2025
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Continued from LIC809...
Facility has an internet access device designated for resident use. Facility has internet service available to residents in care and the telephone was tested an operational during inspection. Smoke and carbon monoxide detectors were tested and operational during inspection. Facility's two fire extinguishers were observed fully charged and were last inspected 05/2025. Facility conducts quarterly disaster drills with the last one conducted 03/2025. Facility has an emergency disaster plan which was last updated 04/2021.

LPA reviewed three (3) resident records and three (3) staff records and observed the following: three (3) of three (3) resident records reviewed contained required documents. Administrator agreed to ensure that all of the required documents are complete and in the resident files in order to bring the facility into compliance with regulation. Three (3) of three (3) staff files reviewed have the required documents. However, three (3) of three (3) staff files reviewed were missing proof of the required initial and annual medication training, (see LIC809D).

LPA reviewed medications and medication logs which were inspected and observed stored in compliance with regulation. Administrator agrees to ensure facility that centrally stored medication logs are maintained in compliance with regulation. Facility does not manage P&I.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 Personnel Report (updated)
  • LIC610 Emergency Disaster Plan (updated)
  • Control of Property – Deed
  • Copy of Administrator’s Certificate (updated)
  • Proof of Liability Insurance (updated)

Observed deficiencies (see LIC809D) were cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator whose signature on form confirms receipt of documents. Appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2025 02:16 PM - It Cannot Be Edited


Created By: Julie Florio On 06/17/2025 at 02:23 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: ANNIE'S FAMILY HOME CARE OF CALISTOGA
FACILITY NUMBER: 286803969

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

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 3 staff records reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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Licensee to submit self-certification that all required initial and annual medication training for all staff has been completed to CCL by POC due date 07/18/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2025


LIC809 (FAS) - (06/04)
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