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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801529
Report Date: 12/30/2025
Date Signed: 12/30/2025 03:08:26 PM

Document Has Been Signed on 12/30/2025 03:08 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:FAIRFIELD MEADOWSFACILITY NUMBER:
486801529
ADMINISTRATOR/
DIRECTOR:		SALVADOR, MARIAFACILITY TYPE:
740
ADDRESS:4526 TOLENAS AVENUETELEPHONE:
(707) 422-2511
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: DATE:
12/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Rosemarie Vister -Designation of Facility Responsiblity TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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At approximately 1:35 pm, Licensing Program Analyst (LPA) Stevenson arrived unannounced to BEGIN a required 1-year annual inspection and was greeted by Rose Marie Vister, Designated Responsible Party (DRP). Administrator Maria Salvador was contacted via telephone and advised of the inspection. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care, all of whom were present during today's inspection. Facility has a Dementia Care Plan, a Hospice waiver for two (2), and is approved for all non-ambulatory residents with approval for one (1) bedridden resident.

At approximately 01:45 PM, LPA initiated a tour of the facility with DRP and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. LPA continues to see evidence of on-going rodent treatment with various traps below kitchen sink and garage used as additional pantry with foods in storage devices. LPA observed large hole in the exterior wall behind garage wash machine and dryer that represent and easier access point for rodent into the garage being used as a pantry/storage. LPA observed worn carpeting with staining throughout the facility as seen in the last annual inspection performed. A drawer face to the left of the stove was loose and evidence of water intrusion into the sheet rock in the bathroom walls was evident. In addition, LPA observed two (2) rotten deck boards outside the living room sliding door that represent a tripping hazard. 4 of 8 smoke detectors either required new batteries or did not emit the proper volume of alarm and a Plan of Correction (POC) was made to address a number of the facility issues.A repeat citation 87303(a) for grounds out of repair and civil penalty is being assessed. (See LIC809-D page)

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. Cabinets containing cleaning supplies and medicines and other items that could pose a risk were locked.
Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2025
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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Document Has Been Signed on 12/30/2025 03:08 PM - It Cannot Be Edited


Created By: Star Stevenson On 12/30/2025 at 02:25 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: FAIRFIELD MEADOWS
FACILITY NUMBER: 486801529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 4 out of 8 instances of facility repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2026
Plan of Correction
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Licensee to provide photo proof of installation of 4 new & properly working smoke detectors to replace older discolored yellow detectors that are not emitting loud enough alarms. In addition, licensee to submit evidence of replacement of 2 deck boards just outside central sliding doors that represent a tripping hazard, repair of loose drawer face to the left of stove, as well as, evidence of a hole in the exterior wall behind wash/dry machines narrowed with wire, wood or other by 01/28/2026
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:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2025


LIC809 (FAS) - (06/04)
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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: FAIRFIELD MEADOWS
FACILITY NUMBER: 486801529
VISIT DATE: 12/30/2025
NARRATIVE
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continued from LIC809

LPA will return at a later date to continue the annual required inspection to further inspect facility repair and upkeep, as well as, facility, staff and resident files.

LPA will request updated copies of upon completion of final inspection visit including:
1)Updated Liability insurance
2)Updated LIC500 Personnel Report
3)Updated LIC9020 Register of Facility Residents.

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 Rose Marie Vister (DRP) and Appeal rights were given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC809 (FAS) - (06/04)
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