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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803084
Report Date: 12/11/2025
Date Signed: 12/11/2025 03:33:34 PM

Document Has Been Signed on 12/11/2025 03:33 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:RIO VISTA CARE HOMEFACILITY NUMBER:
486803084
ADMINISTRATOR/
DIRECTOR:		GUINTU,KEANUFACILITY TYPE:
740
ADDRESS:185 TRINITY COURTTELEPHONE:
(707) 374-3777
CITY:RIO VISTASTATE: CAZIP CODE:
94571
CAPACITY: 6CENSUS: 5DATE:
12/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Maria LAquindanum-Administrator TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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At approximately 10:30am, Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection visit. LPA was greeted by Administrator, Maria Laquindanum. Facility is a Residential Care Facility for the Elderly that has a fire clearance approved for a capacity of 6 non-ambulatory, 1 can be bedridden with hospice waiver for 2. There are currently 5 residents in care. LPA reviewed Guardian Roster and found that two staff (S4 & S5) working on shift were not associated to the facility roster (Deficiency cited, see 809D).

LPA toured the building and grounds which was found to be clean and at a comfortable temperature. LPA observed all walkways and exits to be unobstructed. All required postings were in a highly visible area. Fire extinguishers were charged and last inspected 5/15/2025. Fire alarms and carbon monoxide detector were tested and operational. Outdoor emergency exit clear from obstruction. Outdoor furniture accessible for resident use. Water temperature measured faucets accessible to residents which is within the allowable range of 105 to 120 degrees F. Disaster drills are conducted quarterly. All bedrooms were equipped with lighting, a night stand and chest of drawers. Resident bathroom observed to have bath mat and grab bar. Facility had an ample supply of linens, towels and extra hygiene products for residents.

LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable foods. Few canned goods were found to be expired and expiration dates were not noted in refrigerated containers(Technical Violation given). Facility kitchen, refrigerators and freezers were clean. Toxins placed under kitchen sink were not locked. In addition, toxins also found under sink not locked in restroom accessible to residents. (Deficiency Cited, see 809D) Sharps and knives were locked in kitchen drawer. LPA observed unlocked drawer with pre poured medications in kitchen(Deficiency Cited, see 809D). Technical violation given for pre-poured medications.

Continued onto 809C...
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2025
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: RIO VISTA CARE HOME
FACILITY NUMBER: 486803084
VISIT DATE: 12/11/2025
NARRATIVE
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continued from 809....

LPA reviewed 4 staff records. S1,S2 lacked LIC503. S3 lacked LIC503 with TB Clearance (Deficiency Cited, See 809D) S1,S4,S5 did not have completed annual training certification (Deficiency Cited, see 809D).

LPA reviewed 4 of 4 resident records. All required documentation was present. Physician reports were up to date. Personal Rights LIC613 missing signature for 2 residents (Technical Violation,given) .
LIC602 not updated for R5 (Deficiency Cited, See 809D).

LPA and Admin conducted a spot check of medication and medication records, all records up to date. Medication is centrally stored and locked.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:



LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

***LPA had conversation with Admin recommending TSP. At this time Admin is not interested but will let CCL know if decision changes.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted and report read with Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC809 (FAS) - (06/04)
Page: 7 of 7
Document Has Been Signed on 12/11/2025 03:33 PM - It Cannot Be Edited


Created By: Ethel Contreras On 12/11/2025 at 02:41 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: RIO VISTA CARE HOME
FACILITY NUMBER: 486803084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA and admin observation the licensee did not comply with the section cited above in cabinet under kitchen sink and resrroom sink found to be stored with chemicals and not locked, acessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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2
3
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Licensee to submit LIC9098 Self Certifying that all chemicals and toxins will be kept locked and inaccesible to residents by Plan of Correction due date 12/12/2025.
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA and admin record review and observation the licensee did not comply with the section cited above in that
LIC503 not found for S1,S2,S3. TB clearance missing for S2 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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3
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Licensee to submit self certification LIC9098 that employees will get a LIC503 Health Screening by Plan of Correction. Licensee to submit proof of LIC503 by 12/19/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2025 03:33 PM - It Cannot Be Edited


Created By: Ethel Contreras On 12/11/2025 at 02:41 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: RIO VISTA CARE HOME
FACILITY NUMBER: 486803084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and admin observation the licensee did not comply with the section cited above in that Medication found unlocked in kitchen drawer, accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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3
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LIcensee to submit self certification LIC9099 that all medication will be kept centrally locked and stored inaccessible to residents by plan of correction due date 12/12/2025
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2025 03:33 PM - It Cannot Be Edited


Created By: Ethel Contreras On 12/11/2025 at 02:41 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: RIO VISTA CARE HOME
FACILITY NUMBER: 486803084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based onLLPA and admin observation the licensee did not comply with the section cited above in which S4 and S5 not associated to facility Guardian Roster poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2025
Plan of Correction
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2
3
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Licensee to submit proof that S4 and S5 have been added to the facility roster by plan of correction due date 12/18/2025
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and admin record review and observation the licensee did not comply with the section cited above in Required 20 hour annual training not found for S1,S4 and S5 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2025
Plan of Correction
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2
3
4
Licnesee to submit proof of required 20 hour training for all staff by plan of correction due date 12/23/2025
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2025 03:33 PM - It Cannot Be Edited


Created By: Ethel Contreras On 12/11/2025 at 03:17 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: RIO VISTA CARE HOME
FACILITY NUMBER: 486803084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)(1)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
.Based on LPA and admin observation and record review, the licensee did not comply with the section cited above in LIC602 not up to date for R5 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2025
Plan of Correction
1
2
3
4
Licensee to submit proof of updated LIC602 by plan of correction due date 12/23/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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