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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803996
Report Date: 10/27/2025
Date Signed: 10/27/2025 05:55:09 PM

Document Has Been Signed on 10/27/2025 05:55 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:AGING IN THE BAY 2FACILITY NUMBER:
486803996
ADMINISTRATOR/
DIRECTOR:		MENDAROS, CHARMAINEFACILITY TYPE:
740
ADDRESS:1325 POTRERO CIRCLETELEPHONE:
(510) 388-7352
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 6CENSUS: 6DATE:
10/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:27 AM
MET WITH:Charmaine Mendaros-Administrator TIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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At approximately 10:15, Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection visit. LPA was greeted by designee/caregiver Mary Ann Ordono. Administrator Charmaine Mendaros arrived shortly later. Facility is a Residential Care Facility for the Elderly that has a fire clearance approved for six non-ambulatory residents and one bedridden in rooms 1,2,4 and 5 only. Approved hospice waiver for 5 residents.

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 2/14/2025. Fire alarms and carbon monoxide detector were tested and operational. Outdoor emergency exit clear from obstruction. Water temperature measured at 116.4 degrees F at faucets accessible to residents which is within the allowable range of 105 to 120 degrees F. Disaster drills are conducted quarterly with the last drill conducted on 10/01/2025.

All bedrooms were equipped with lighting, a night stand and chest of drawers. Resident bathroom lacked bath mat, grab bar was observed (Technical Advsory given). LPA observed plastic mat in shared resident room #2 to be lifted and have ripping, presenting a tripping hazard to resident (Technical Violation given).
LPA observed a Fire Clearance Violation as closet in shared room 1 and 2 to be occupied for live in staff. Mattress with bedding, personal items and camera was observed inside residents closet (Deficiency Cited, see 809D) **Immediate Civil Penalty assessed in the amount of $500 due to fire clearance violation. LPA had conversation about the importance and potential dangers of having an unapproved room. Mattress was removed during inspection.

Continued onto 809C...
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2025
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: AGING IN THE BAY 2
FACILITY NUMBER: 486803996
VISIT DATE: 10/27/2025
NARRATIVE
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continued from 809....

LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable foods. Emergency water was observed to meet the 72 hour emergency supply, however emergency food was not observed. LPA advised admin to supply more non-perishables for emergency (Technical advisory given).

Facility kitchen, refrigerators and freezers were clean, and food was stored properly with expiration dates noted. LPA observed ants to be in pantry not inside food. However, admin stated Pest Control comes monthly for treatment. LPA verified through receipts. Toxins are stored in a locked cabinet and inaccessible to residents. Sharps and knives were locked in kitchen drawer. Facility had an ample supply of linens, towels and extra hygiene products for residents.

LPA reviewed 6 of 6 resident records. All required documentation was present. Physician reports were up to date.
LPA reviewed 5 staff records. LPA observed CPR Certificate number that belongs to staff (S1) no longer working at facility to be the same number for S2, S3 and S4. LPA verified CPR Certification on website and verified that S1 certification belonged to S1 only. CPR certification number for S5 was not found in website. CPR for S6 was expired as of 10/03/2025 also appeared to have the same certification number as S1,S2,S3 and S4 (Deficiency Cited, see 809D).

LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet.

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 (Retrieved during visit)
Liability Insurance

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: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2025 05:55 PM - It Cannot Be Edited


Created By: Ethel Contreras On 10/27/2025 at 05:19 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: AGING IN THE BAY 2
FACILITY NUMBER: 486803996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and admin observation], the licensee did not comply with the section cited above in that shared resident room #1 and #2 closet is being occupied as a living space for staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2025
Plan of Correction
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Licensee to submit LIC 9098 self certifying that mattress will no longer be placed in closet and no staff to be sleeping in resident closet or other areas in facility without a fire clearance or permit. *** Immediate Civil Penalty assessed in the amount of $500 due to fire clearance violation.
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:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2025 05:55 PM - It Cannot Be Edited


Created By: Ethel Contreras On 10/27/2025 at 05:19 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: AGING IN THE BAY 2
FACILITY NUMBER: 486803996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review , the licensee did not comply with the section cited above in First aid/CPR Certifications for Staff 2,Staff 3,Staff 4 not verifiable and contained the same certification number. Staff 5 certification not verifiable and Staff 6 expired CPR.

which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
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Licensee to submit CPR/First aid training for S2,S3,S4,S5,S6 by plan of correction due date 11/03/2025.
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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2025


LIC809 (FAS) - (06/04)
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