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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804025
Report Date: 11/13/2025
Date Signed: 11/13/2025 03:12:57 PM

Document Has Been Signed on 11/13/2025 03:12 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:ZEALCARE HOMEFACILITY NUMBER:
286804025
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, MADONNA GRACEFACILITY TYPE:
740
ADDRESS:2504 REDWOOD RD.TELEPHONE:
(707) 258-9348
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: 5DATE:
11/13/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Corina Anguiano, Caregiver/Designated Responsible PartyTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 11/13/2025, at approximately 1:15 PM, Licensing Program Analyst (LPA) Julie Florio arrived at facility unannounced, to conduct a Case Management - Deficiencies visit and met with Corina Anguiano, Caregiver/Designated Responsible Party (DRP). Administrator, Madonna Grace Martinez was contacted via telephone and DRP left a message regarding today's visit. LPA toured the building and found it to be clean and orderly. Food was plentiful and stored in a safe manner.

Today's Case Management - Deficiencies visit is to follow up on areas on non-compliance identified and discussed with Licensee during LPA's quarterly Legal/Non-Compliance visit on 10/22/2025 and previously uncleared deficiencies issued since facility was placed on the current non-compliance plan on 06/26/2024, which Licensee agreed to clear by EOB 10/31/2025. To date, the Department has not received any of the requested information or communication from Licensee. As a result, LPA is issuing citations for the following areas of concern which are reflected in each of the uncleared plans of correction issued since 06/26/2024:
  • Medication Administration
  • Prompt Response to Resident's Representative
  • Admissions Agreements
  • Reporting Requirements
  • Staff Training
  • Appraisal Needs and Services Plans
  • Staffing
  • Postural Support Orders

Continued on LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2025
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: ZEALCARE HOME
FACILITY NUMBER: 286804025
VISIT DATE: 11/13/2025
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Continued from LIC809...

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, LIC-809Ds with Plans of Correction, and Appeal Rights discussed and provided to DRP. Signature on forms confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/13/2025 03:12 PM - It Cannot Be Edited


Created By: Julie Florio On 11/13/2025 at 02:12 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: ZEALCARE HOME
FACILITY NUMBER: 286804025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2025
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not ensure medications were administered as
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Licensee to ensure residents are assisted with medication as ordered by physician. Licensee to conduct training for all staff on medication procedures. Training to be scheduled and completed by11/14/2025. Sign in sheet of completed training to be submitted to CCL by 11/14/2025.
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ordered. Resident did not receive eye drops as ordered and resident antibiotics were not given as ordered. This poses an immediate Health risk to residents in care.
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Type B
11/14/2025
Section Cited
CCR87468.1(a)(9)

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87468.1 Personal Rights of Residents in All Facilities: (9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement is not met as evidenced by: Based on interviews conducted, Licensee did not promptly respond to resident representatives
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Licensee to ensure residents representatives communications are answered promptly. Licensee to review regulation 87468.1 and submit self certification of their understanding. Self certification to be submitted to CCL by POC date of 11/14/2025.
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This poses a potential personal rights risk to residents 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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/13/2025 03:12 PM - It Cannot Be Edited


Created By: Julie Florio On 11/13/2025 at 02:20 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: ZEALCARE HOME
FACILITY NUMBER: 286804025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2025
Section Cited
CCR
87507(e)

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87507 Admission Agreements:(e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification.
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Licensee shall review regulation 87507 and submit self certification that they understand and will comply going forward. Self certification shall be submitted to CCL by POC date of 11/14/2025.
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This requirement is not met as evidenced by: Based on interviews conducted, resident nor their representative received a copy of the admission agreement immediately after signing. This poses a potential Health, Safety or Personal rights risk to residents in care.
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Type B
11/14/2025
Section Cited
CCR87211(a)(1)(D)

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87211 Reporting Requirements:(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on records reviewed
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Licensee shall review regulation 87211 and submit self certification that they understand and will comply going forward. Self certification shall be submitted to CCL by POC date of 11/14/2025.
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Licensee did not follow regulation by not notifying the Department of a residents visit to the emergency room. This poses a potential Health, Safety or Personal rights risk to residents 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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/13/2025 03:12 PM - It Cannot Be Edited


Created By: Julie Florio On 11/13/2025 at 02:24 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: ZEALCARE HOME
FACILITY NUMBER: 286804025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2025
Section Cited
CCR
87412(c)

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87412 Personnel Records:(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not have documentation of completed staff training. This poses a
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Licensee shall submit evidence of completed staff training for All staff to CCLD by POC date of 11/14/2025.
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potential Health, Safetly or Personal Rights risk to residents in care.
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Type B
11/14/2025
Section Cited
CCR85068.2(b)

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85068.2(b) Needs and Service Plan. If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan…..***Based upon records reviewed, this requirement has not been met as evidenced by:
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Licensee agrees to ensure that all staff obtain and complete staff required annual training-ensure all staff have required training. Submit proof if training to CCL by POC due date of 11/14/2025.
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 Appraisal & Needs Service Plan for 5 out of 5 residend as of 04/01/2025 is not complete or signed by all partiesThis poses a potential Health and Safety risk to clients 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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/13/2025 03:12 PM - It Cannot Be Edited


Created By: Julie Florio On 11/13/2025 at 02:29 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: ZEALCARE HOME
FACILITY NUMBER: 286804025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2025
Section Cited
HSC
1569.269(a)(6)

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§1569.269 Enumerated rights; severability (a)(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on file review,
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Licensee agrees to submit a self-certifaction that they understand regulation 1569.269 as it pertains to the care and safety of residents to CCL by POC due date of 11/14/2025.
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interviews conducted and record review, the licensee did not ensure that facility was staffed sufficiently or that staff were competently trained to ensure injuries were not caused to R1 during their care, which poses a health, safety, and/or personal rights violation to residents in care.
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Type B
11/14/2025
Section Cited
CCR87608(a)(5)(B)

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87608 Postural Supports (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
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Licensee to submit a self-certification that they unerstand the requirements for the half anf full bedrails in the operation of the facility per title 22 regulations to CCL by POC due date 11/14/2025.
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Based on file review, interviews conducted and record review, the licensee was unable to produce orders for full bedrails observed on R1's hospital bed as required per regulation, which poses a potential health, safety, and/or personal rights violation to residents 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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/13/2025 03:12 PM - It Cannot Be Edited


Created By: Julie Florio On 11/13/2025 at 02:51 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: ZEALCARE HOME
FACILITY NUMBER: 286804025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2025
Section Cited
HSC
1569.625

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H&S Code 1569.625 Staff training; legislative findings; contents: training requirements . This requirement is not met as evidenced by: ***Based on file review & interview with Licensee, the licensee failed to ensure that all staff had completed the required annual training as required by
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Licensee agrees to ensure that all staff obtain and complete staff required annual training-ensure all staff have required training. Submit proof if training to CCL by POC due date of 11/14/2025.
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 title 22 regulations and H&S Code which poses a potential health and safety risk to residents in care. LPA observe during file reviews 3 out of 3 staff have not completed all of the required 20 hours of ongoing annual training.
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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: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
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