486803781-12-23-2025-21-AS-SSTN-DPMRJU-20251223120430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803781
Report Date: 12/23/2025
Date Signed: 12/23/2025 12:04:44 PM

Document Has Been Signed on 12/23/2025 12:04 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:	ADELAIDE HOME II		FACILITY NUMBER:	486803781
ADMINISTRATOR/ DIRECTOR:	JASMINE ALISCAD		FACILITY TYPE:	740
ADDRESS:	1155 MAHOGANY CT		TELEPHONE:	(707) 207-3941
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 4		CENSUS: 4	DATE:	12/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:			TIME VISIT/ INSPECTION COMPLETED:	12:25 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 09:00 AM, Licensing Program Analyst (LPA) Stevenson arrived unannounced to conduct a required 1-year annual inspection and was greeted by LVN caregiver Pam Deleon who has Designation of Facility Responsibility (RP). Administrator Jasmine Aliscad was called and informed of inspection and arrived later at 09:50 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with four (4) residents in care. Two residents were present and one was away with Administrator at an assessment and another resident was away at day program. Facility has a Dementia Care Plan, is approved for all non-ambulatory residents and has a hospice waiver for one (1) and is vendorized with North Bay Regional Center (NBRC). At approximately 9:30 AM, LPA initiated a tour of the facility with RP and observed the following: Facility is a one story home, was a comfortable temperature, free from odors, and passageways were free from obstructions. 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 products, incontinent care supplies, 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 food and water supply. In addition each resident has a dedicated emergency go-bag. There is a shaded seating area with a electronic retractable awning in the backyard with outdoor space and stainless steel Bar-B-Que for use. In addition, facility has wide wheelchair ramps in front and back of the home. LPA observed 1 locked shed in the backyard which LPA inspected and observed the contents to consist of PPE supplies, extra resident care equipment, holiday decorations, and a large emergency generator. Continued on LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

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: ADELAIDE HOME II	FACILITY NUMBER: 486803781
	VISIT DATE: 12/23/2025

NARRATIVE

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Continued from LIC809C...
LPA observed an activity schedule and were informed that the residents play bingo, play indoor bowling, watch movies, and engage in sensory activities. Facility also hosts holiday parties for the residents and throws a large Halloween, Thanksgiving, Christmas, and 4th of July party in a central location where all five (5) care homes attend. Facility has internet access and provides a designated internet access device for resident use. Facility has a telephone which was tested during inspection.

Facility's fire extinguisher was observed charged and was last serviced 10/2025. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Centralized Fire system was tested and all fire doors closed automatically. Facility conducts monthly disaster drills, and the most recent drill was conducted 12/2025. LPAs observed the facility's infection control plan, first aid kit, PPE, and emergency supplies. LPAs reviewed facility's emergency disaster plan last updated 1/2025.

At approximately 10:30 AM, LPA conducted file review. Four (4) staff files and four (4) resident files were reviewed. One (1) staff member hired 10/14/2025 was noted to have evidence of initial 40 hours of training and orientation within the 1st four (4) weeks of hire, but did not have evidence of the full 14 hours of dementia training or the full 8 hours of postural supports/restricted conditions, hospice care training in those 40 hours and a Technical Violation was issued. Four (4) of four (4) resident files reviewed contained all the required documentation per regulation.

Administrator states they coordinate residents' medical and dental appointments and transportation to and from visits.

Medications and P&I were reviewed and observed managed and maintained within regulation.

Updated copies of the following documents were obtained during this visit:

LIC500 - Personnel Report (updated)
LIC610D Emergency Disaster Plan (updated)
Proof of Liability Insurance
LIC 9020 Register of Facility Clients/Residents

Technical Violation is cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), may result in a civil penalty assessment.

Exit interview conducted with Administrator and Appeal rights were given. Signature on form confirms receipt.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

LIC809 (FAS) - (06/04)

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