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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803882
Report Date: 10/02/2025
Date Signed: 10/02/2025 04:43:53 PM

Document Has Been Signed on 10/02/2025 04:43 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:CASA ISABELLA IIFACILITY NUMBER:
486803882
ADMINISTRATOR/
DIRECTOR:		VILLEGAS, ART GFACILITY TYPE:
740
ADDRESS:680 SNAPDRAGON PLTELEPHONE:
(707) 344-0839
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY: 6CENSUS: 4DATE:
10/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Art Villegas, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
NARRATIVE
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At approximately 12:45 PM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and was greeted by Caregiver (CG) Sombito. Administrator Art Villegas arrived at 1:15 PM. Casa Isabella II is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a single story ranch house. The facility has an approved fire clearance for six (6) non-ambulatory residents. The facility has a Hospice Waiver for three (3) residents. Upon arrival, LPA was informed that there were four (4) residents in care and two (2) staff members on-site. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 1:05 PM, LPA toured the facility. All exits were clear and unobstructed. The facilities one (1) fire extinguisher was last serviced and tagged in 12/2024. LPA observed that there were no functioning lights in the bathroom attached to the semi-private room at the rear of the facility. This deficiency will be cited. The remainder of the facility was observed to be sufficiently lighted. LPA inspected five (5) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. LPA observed an unsecured bottle of "Gorilla Glue" in the bathroom attached to the semi-private room at the rear of the facility. This deficiency will be cited. All other toxins were observed to be stored inaccessible to residents. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for a sample of sinks in facility were observed to exceed the Title 22 regulations of 105 to 120 degrees Fahrenheit. Sample of sinks tested were at 142.7, 126 and 140.1 degrees Fahrenheit. This deficiency will be cited. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational. Continued on 809-C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2025
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: CASA ISABELLA II
FACILITY NUMBER: 486803882
VISIT DATE: 10/02/2025
NARRATIVE
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...Continued from 809

Administrator Villegas stated the facility is conducting fire and emergency drills monthly. However, LPA observed that the required Emergency Disaster Drill log was not at the facility; however LPA was able to view a picture of the Disaster Drill Log. A Technical Violation will be issued for this deficiency.

At approximately 1:55 PM, LPA reviewed two (2) resident files. One (1) of two (2) resident files for Resident 1 (R1) were observed to not have a current LIC 625 Appraisal/Needs and Service Plan. LPA further observed that R1 did not have an LIC 603 Pre-Admission Appraisal form. These deficiencies will be cited. All other required documentation was observed to be present in the resident's files. LPA reviewed two (2) staff files. All staff files were observed with all required documentation including First Aid and CPR certification and proper training documentation. During the facility inspection LPA observed unsecured medications in a night stand in the walk in closet located off the bathroom attached to the semi-private room at the rear of the facility. This deficiency will be cited. LPA spot checked Medication for two (2) residents. With the exception of the unsecured medications previously mentioned, LPA observed all medications to be centrally stored, secure and with proper documentation. The facility does not handle resident’s monies for personal and incidental items.

Art Villegas’s Administrator Certification 7019452740 is current with an expiration date of 6/9/2027.

LPA requested the following documents be submitted to Community Care Licensing by 11/2/2025:



LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Proof of Liability Insurance

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809Ds, Plan of Corrections, LIC 9102, 811 Confidential Names and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2025 04:43 PM - It Cannot Be Edited


Created By: Robert Frank On 10/02/2025 at 03:41 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: CASA ISABELLA II
FACILITY NUMBER: 486803882

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

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
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Based on observation, the licensee did not comply with the section cited above in that medications were left unsecured in a night stand in the walk in closet located off the bathroom attached to the semi-private room at the rear of the facility. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2025
Plan of Correction
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Licensee will provide an LIC 9098 self certifying that medications will be kept secured to Community Care Licensing (CCL) by POC due date of 10/3/2025. Licensee will also conduct medication management training will all staff members and provide proof of training to CCL by 10/20/2025. Proof of training will include staff signatures.
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2025 04:43 PM - It Cannot Be Edited


Created By: Robert Frank On 10/02/2025 at 03:41 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: CASA ISABELLA II
FACILITY NUMBER: 486803882

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(d)
Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPA observed that there were no functioning lights in the bathroom attached to the semi-private room at the rear of the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2025
Plan of Correction
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Licensee to provide photographic proof of functioning lights in the bathroom attached to the semi-private room at the rear of the facility to Community Care Licensing (CCL) by POC due date of 10/16/2025.
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that Hot water temperatures for a sample of sinks in facility were observed to exceed the Title 22 regulations of 105 to 120 degrees Fahrenheit. Sample of sinks tested were at 142.7, 126 and 140.1 degrees Fahrenheit. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2025
Plan of Correction
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Licensee to maintain a daily hot water temperature log showing hot water within Title 22 regulations of 105 to 120 degrees Fahrenheit. Licensee to submit daily hot water log to CCL by POC due date of 10/16/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2025 04:43 PM - It Cannot Be Edited


Created By: Robert Frank On 10/02/2025 at 03:41 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: CASA ISABELLA II
FACILITY NUMBER: 486803882

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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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Based on observation, the licensee did not comply with the section cited above in that an unsecured bottle of "Gorilla Glue" was observed in the bathroom attached to the semi-private room at the rear of the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2025
Plan of Correction
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Licensee to conduct training with all staff members to review CCR 87309(a) and provide proof to Community Care Licensing (CCL) by POC due date of 10/16/2025. Proof of training will include staff signatures.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that LPA observed that R1 did not have an LIC 603 Pre-Admission Appraisal form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2025
Plan of Correction
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Licensee to submit a completed and signed LIC 603 Pre-Admission Appraisal form for R1 to CCL by POC due date of 10/16/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2025 04:43 PM - It Cannot Be Edited


Created By: Robert Frank On 10/02/2025 at 03:41 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: CASA ISABELLA II
FACILITY NUMBER: 486803882

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that Resident one's (R1) personal file was observed to not have a current LIC 625 Appraisal/Needs and Service Plan (last LIC 625 was done on 8/19/2024) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2025
Plan of Correction
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3
4
Licensee to submit a completed and signed LIC 625 Appraisal/Needs and Service Plan for Resident R1 to Community Care Licensing by POC due date of 10/16/2025.
Section Cited
Deficient Practice Statement
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
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