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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803930
Report Date: 03/25/2025
Date Signed: 03/27/2025 05:57:16 PM

Document Has Been Signed on 03/27/2025 05:57 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:A&C CAREFACILITY NUMBER:
486803930
ADMINISTRATOR/
DIRECTOR:		YOUNG, ALEXFACILITY TYPE:
740
ADDRESS:5144 DARTMOOR CIRCLETELEPHONE:
(415) 812-1517
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 6CENSUS: 2DATE:
03/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:53 AM
MET WITH:Chuluunchimeg Young - AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 03/25/2025 at approximately 9:45 AM Licensing Program Analyst (LPA) Stevenson arrived and first met with Chuluunchimeg Young licensee/administrator and later her husband Alex Young who is co-licensee and an administrator to conduct an unannounced Annual Required – 1 yr. inspection of this facility. The facility has capacity for 6 clients including 5 non-ambulatory and 1 bedridden resident with a hospice clearance for 2. The facility currently provides care for 2 residents, none of which are receiving hospice services and none of which a diagnosis of dementia.

At approximately 10:15 AM LPA continued with a tour of the facility with Administrator Chuluunchimeg Young and facility was found to be spacious, bright, clean, without odors and at a comfortable temperature with all exits free from obstruction. All required postings and signage at the front of the facility were found to be in order with information easily accessible for staff and residents. Residents have access to a sunroom with views of the bay, and shaded gazebo, lounging area, snacks, coffee station, large TV etc.
Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found throughout the facility to be recently purchased on 1/04/2025. Smoke and carbon monoxide detectors are interconnected throughout the facility, were tested and found to be functioning. There was a sufficient supply and variety of both perishable and nonperishable and healthy foods as required by Title 22 Regulations. Licensee was advised to ensure that all food, once removed from it original/commercial bag was labeled/dated.

The majority of cleaning supplies and other toxins were safely stored in a locked closet in the hallway, licensee was reminded to ensure that once cleaning supplies were used that they were quickly returned to their locked storage; today both toilet bowel cleaner and oven cleaner were found just outside locked storage closet.
A lockable staff area was noted to be unlocked with potential access to over-the-counter supplements and meds used by staff and a technical violation was issued with a suggestion to use a more readily locked door like a keypad door knob or locking closet to ensure easier compliance.
Continued onto LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
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: A&C CARE
FACILITY NUMBER: 486803930
VISIT DATE: 03/25/2025
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Continued from LIC809
Sharps that could pose a danger if available to residents were found secured under the kitchen sink. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. Water was measured at faucets accessible to residents and measured between 114.6 and 112.7 degrees F which is within regulation.

At approximately 11:30 AM LPA conducted file review for staff and found all staff to have appropriate training, health clearance, TB testing and background clearance to work. LPA also conducted a file review for all residents. Upon review, LPA found that all resident Needs & Service Plans and Physician's Reports, TB clearance, admissions agreements and Consent from medical treatments to be current.

A review and observation of the house kept MAR along with interviews revealed that one (1) of two (2) clients, client one (C1) in care did not have the day before medicines logged(picture taken) (Type B citation issued)

Deficiencies are cited from the California Code of Regulations (CCRs) and/or 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.

This report was reviewed with Alex Young whose signature here indicated understanding and Appeal rights were given.

LPA requested the following documents be sent to CCL by 03/25/2025:LIC 308 Designated Facility Responsibility, LIC 500 Personnel Summary, LIC 9020 Register of Facility Client’s/Resident’s, Liability Insurance (current)

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC809 (FAS) - (06/04)
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Document is an Amendment of Original Document on 04/01/2025 09:28 AM


Created By: Star Stevenson On 03/25/2025 at 01:41 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: A&C CARE
FACILITY NUMBER: 486803930

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above in 1out of 2 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2025
Plan of Correction
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Licensee will submit writing to CCL by 03/26/2025 a letter that they understand that an accurate "record of each dose (of medicines) is maintained in the residents record.
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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025


LIC809 (FAS) - (06/04)
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