<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804175
Report Date: 04/20/2026
Date Signed: 04/20/2026 01:24:39 PM

Document Has Been Signed on 04/20/2026 01:24 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:DIVINE MERCY FAMILY HOMEFACILITY NUMBER:
486804175
ADMINISTRATOR/
DIRECTOR:		BUI, MARIAFACILITY TYPE:
740
ADDRESS:105 MAYWOOD DRTELEPHONE:
(707) 334-1709
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 4DATE:
04/20/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Venus StanfordTIME VISIT/
INSPECTION COMPLETED:
01:40 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 9:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to open a complaint investigation. LPA met with Venus Stanford. During this investigation, LPA observed there were several metal bars that were inserted into a hole in the door jam and protruding into the wood of the door, preventing the door from opening. LPA observed the metal bars were on a residents exit door, the front door and rear exit door of the facility. The metal bar in the residents exit door was located at the top of the door jam. LPA requested staff to remove the bar, but it was located higher than they could reach. All metal bars have been removed from doors. LPA requested the holes be filled to prevent the use of the metal bars in the future. This is an Immediate Safety risk to residents in care and am immediate civil penalty is being issued in the amount of $500.

LPA was informed on March 24, 2026 that there was a change in ownership of this business. The letter stated the change took place on March 1, 2026. The Department was not notified within the timelines provided in regulation. On 03/25/2026, LPA requested the written notifications made by the Licensee to the families and LPA has not received copies.

On 04/06/2026, LPA received an Unusual incident report regarding resident, R1, eloping from the facility on 03/25/2026. Staff went to the room to wake R1 and found they were not in the room. Staff searched the surrounding area and notified the responsible party. Law Enforcement was notified. R1 was found at approximately 1:00PM the same day, in a parked vehicle in the neighborhood.
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, may result in a civil penalty assessment.
This report was reviewed with Venus Stanford and Appeal rights were given.
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Christopher Arnhold
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2026
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 4
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)
Page: 2 of 4
Document Has Been Signed on 04/20/2026 01:24 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 04/20/2026 at 12:22 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: DIVINE MERCY FAMILY HOME
FACILITY NUMBER: 486804175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2026
Section Cited
CCR
87203

1
2
3
4
5
6
7
87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observation, LPA found metal rods placed between the door
1
2
3
4
5
6
7
All metal rods were removed. Violation cleared during visit.
8
9
10
11
12
13
14
and the door jam of an emergency exit, preventing the door from opening. This poses an Immediate Safety risk to persons in care. An immediate civil penalty is being issued in the amount of $500.
8
9
10
11
12
13
14
Type B
05/08/2026
Section Cited
CCR87224(5)(a)

1
2
3
4
5
6
7
87224 Eviction Procedures: (A) The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not provide at least a 60 day written notice
1
2
3
4
5
6
7
Licensee sent notices to residents and responsible parties. Cleared during visit.
8
9
10
11
12
13
14
to residents or responsible parties regarding the change of ownership of the facility. This poses a potential Health, Safety or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
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:
Christopher Arnhold
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/20/2026 01:24 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 04/20/2026 at 12:55 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: DIVINE MERCY FAMILY HOME
FACILITY NUMBER: 486804175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2026
Section Cited
CCR
87705(d)

1
2
3
4
5
6
7
(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions.This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee replaced audiable alerts on exit doors. Cleared during visit.
8
9
10
11
12
13
14
Based on records reviewed, Licensee did not ensure the exit door alarm was operational and loud enough for staff to be aware of resident leaving. This poses an Immediate Health, Safety or Personal Rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:
Christopher Arnhold
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2026


LIC809 (FAS) - (06/04)
Page: 4 of 4