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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803119
Report Date: 07/22/2025
Date Signed: 07/22/2025 12:52:37 PM

Document Has Been Signed on 07/22/2025 12:52 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:C & C RESIDENTIAL CARE HOME INC.FACILITY NUMBER:
486803119
ADMINISTRATOR/
DIRECTOR:		CORSIGA, ALMAFACILITY TYPE:
740
ADDRESS:2018 BLUEBIRD WAYTELEPHONE:
(707) 344-2628
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 5DATE:
07/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Licensee Alma CorsigaTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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At approximately 9:35 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-Year Visit and was greeted by a caregivers. Alma Corsiga, Licensee, was contacted by phone and arrived at approximately 9:50 AM. LPA was informed there were five (5) residents in care; two (2) were away at Day Program and three (3)) were present during inspection. Facility is a Residential Care Facility for the Elderly (RCFE) with an approved dementia plan and fire clearance capacity of six (6) non-ambulatory residents and hospice waiver for two (2) residents.

At approximately 10:00 AM, LPA initiated a tour of the facility and observed the following: Facility is a one-story home, was a comfortable temperature, free of odors and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed client showers with grab bars an non-slip mats as required. LPA observed a supply of clean linens, incontinent care products, and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets in communal areas containing cleaning supplies and other items that could pose a risk were observed locked. Facility has at least two days of perishable foods and a supply of non-perishable foods. A large approximately one (1) foot long fish that a staff member had caught was observed to be wrapped in an absorbable cloth chux in the freezer and not stored in an air tight bag and labeled with the date per regulation (Type B) deficiency cited.
Medications were centrally stored and locked. There is outdoor space for activities. LPA observed toys, games, video games, and an ipad for resident use. In addition LPA observed an activity schedule, as well as, an opportunity for residents to attend area swim programming. An approximately three inch step was observed leading to an outside activity/office building that poses a potential trip hazard and a technical advisory was issued to install a small transition step or hand railing to reduce the threat.

Facility has a fire extinguisher, which was last inspected May 2025 as is fully charged. Smoke and Carbon Monoxide detectors were tested and operational during inspection.

Continued on 809-C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2025
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: C & C RESIDENTIAL CARE HOME INC.
FACILITY NUMBER: 486803119
VISIT DATE: 07/22/2025
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Continued from LIC 809...
At approximately 11:30 AM, five (5) of 5 resident files were reviewed and observed to have required documentation. Licensee states, facility coordinates the residents' medical and dental appointments as needed and provides transportation to and from these visits.

At approximately 12:00 PM LPA initiated file review of five (5) personnel files and 2 of 5 observed, staff one and staff 2 (S1) and (S2)) had no evidence of health screening or TB testing (Type A) citation issued. In addition 2 of 5 staff files observed to be missing evidence of 1st Aid training and intial education training and technical violation issued.

LPA observed medicines to by centrally stored and secure and administered correctly.
P&I money was accounted for and licensee was on the phone during my inspection to secure additional surety bonding to match the amount of money safeguarded in the facility and will send in new bond to Community Care Licensing (CCL)

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, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights provided to Licensee.

Exit interview conducted with Licensee, whose signature on this document confirms receipt.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
LIC 500 Personnel Record
LIC 9020 Register of Facility Resident’s was obtained during inspection today.
Updated Surety bond for higher amount.
*Updated copy of current liability insurance was obtained during inspection today.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2025 12:52 PM - It Cannot Be Edited


Created By: Star Stevenson On 07/22/2025 at 12:08 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: C & C RESIDENTIAL CARE HOME INC.
FACILITY NUMBER: 486803119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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Based on observation, inteview and record review the licensee did not comply with the section cited above in two (2) out of five (5) staff members including TB and health screening which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
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Licensee to review CCR code 87412(a)(11) with requirements for health screening and TB clearance for staff before they begin work and acknowledge understanding of the requirment by end of day 07/24/2025
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:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2025 12:52 PM - It Cannot Be Edited


Created By: Star Stevenson On 07/22/2025 at 12:08 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: C & C RESIDENTIAL CARE HOME INC.
FACILITY NUMBER: 486803119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(9)
General Food Service Requirements
(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.

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 one (1) out of 1 count which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2025
Plan of Correction
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Licensee to review and review with staff, General Food Service Requirments and safety protections 87555(b)(9) including placing and dating meats in airtight containers and acknowledge understanding of regulation 87555(b)(9)
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: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2025


LIC809 (FAS) - (06/04)
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