286804062-6-30-2025-21-AS-JFLO-DJ5TKV-20250630144835

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804062
Report Date: 06/30/2025
Date Signed: 06/30/2025 02:48:43 PM

Document Has Been Signed on 06/30/2025 02:48 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:	4K SENIOR HOME, LLC		FACILITY NUMBER:	286804062
ADMINISTRATOR/ DIRECTOR:	HERNANDEZ, MARIA SOCORRO		FACILITY TYPE:	740
ADDRESS:	4147 MAHER STREET		TELEPHONE:	(707) 226-1293
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY: 6		CENSUS: 6	DATE:	06/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Maria Socorro Hernandez, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 12:30pm, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by staff. Maria Socorro Hernandez, Administrator and Licensee, was contacted via telephone and arrived at facility at approximately 12:45pm. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care, four (4) of whom were present during today's inspection. Facility has a Dementia Care Plan, a Hospice waiver for six (6), is approved for all non-ambulatory residents, and is vendored with the North Bay Regional Center (NBRC). At approximately 1:00 PM, LPA initiated a tour of the facility with Licensee and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. LPA observed egress devices activated on all facility doors. 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 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 activities. LPA inspected a locked storage shed in the backyard which contained care equipment, supplies, and furniture. LPA observed residents watching TV and working on a puzzle in the common area. Facility has internet service and an internet access device designated for resident use. The telephone was tested and was operational during inspection. Continued on LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025

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: 4K SENIOR HOME, LLC	FACILITY NUMBER: 286804062
	VISIT DATE: 06/30/2025

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Continued from LIC809C...

Smoke and carbon monoxide detectors were tested and operational during inspection. Fire extinguisher was observed fully charged and was last inspected 04/2025. Emergency Disaster Plan was reviewed and updated 04/2025. Facility conducts quarterly disaster drills with the most recent drill conducted 05/2025.

At approximately 1:20pm, LPA conducted file review of three (3) staff and three (3) resident files. Three (3) of three (3) staff files reviewed contained all the required documents, proof of training and proof of current First Aid and CPR certification. Three (3) of three (3) resident files reviewed contained all the required documentation.

Licensee state that facility assists with coordinating medical and dental appointments as well as transportation 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. P&I was observed stored and maintained in compliance with regulation.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC400 - Affidavit Regarding Client/Resident Cash Resources
LIC200 - Application Requesting Fire Department Bedridden Clearance

Exit interview conducted with Licensee whose 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: 06/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025

LIC809 (FAS) - (06/04)

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