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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804180
Report Date: 09/25/2025
Date Signed: 09/25/2025 03:17:08 PM

Document Has Been Signed on 09/25/2025 03:17 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 4FACILITY NUMBER:
486804180
ADMINISTRATOR/
DIRECTOR:		MENDAROS, CHARMAINEFACILITY TYPE:
740
ADDRESS:2290 CORMORANT DRIVETELEPHONE:
(510) 388-7352
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 4DATE:
09/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Adminstrator/licensee-Charmaine MendarosTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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At approximately 11:15 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and was greeted by Mary Ann Ordono, Caregiver/Responsible Party (RP). Licensee was contacted via telephone and gave LPA permission to continue with the inspection with the RP. Facility is a Residential Care Facility for the Elderly (RCFE) with four (4) residents in care. All residents were present during today's inspection. Facility has a hospice waiver for four (4), a bedridden waiver for one (1), and is approved for all non-ambulatory residents, and currently has one (1) hospice resident in care.

At approximately 11:30 AM, LPA initiated a tour of the facility with RP and observed the following: Facility is a one story home, was a comfortable temperature, 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 paper products available to residents. Residents' bedrooms were inspected and observed to have the appropriate furnishings as outlined in Title 22 regulations. Bedroom #6 was noted to have medium pile carpet and smelled of urine with RP agreed and licensee indicating the incontinent resident will be moved to a room with laminate flooring and the room will be thoroughly cleaned. (technical violation issued). A rear staff bathroom was noted to have stained baseboard and previously wet sheetrock and licensee was advised to replace both, in addition the top of the refrigerator and microwave hood require cleaning and a technical violation was issued. 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 water supply. Medications were centrally stored and locked. There is a covered seating area in the enclosed front yard with outdoor space for activities. LPA observed a locked shed in the backyard which LPA inspected and observed the contents which consist of tools, chemicals, and extra facility equipment. LPA observed an activity schedule and was informed that the facility conducts morning exercises at least 4 times per week. LPA observed games, puzzles, and activities for residents in care.

Facility's fire extinguisher was observed charged and was last serviced February 2025. Smoke and Carbon Monoxide detectors were tested and operational during inspection, as well as, no-smoking signs and oxygen in use signs were posted.

Continued on LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2025
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 4
FACILITY NUMBER: 486804180
VISIT DATE: 09/25/2025
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Continued from LIC809...
Facility conducts quarterly disaster drills, and the most recent drill was conducted July 2025. LPA observed the facility's infection control plan, first aid kit, PPE, and other emergency supplies. LPA reviewed facility's emergency disaster plan which was llast updated July 2025.

At approximately 11:50 AM, Licensee, Charmaine Menderos arrived. LPA reviewed five (5) staff files. One (1) staff file was not available, one (1) staff had no evidence of 1st Aid/CPR training or finger printing and criminal exception to review. One (1) staff had no evidence of initial 20 hours of training and four (4) or five (5) staff present were not listed on Guardian website as being cleared to work at the facility (Type A citation and POC issued) LPA conducted file review of all five (4) resident files and observed all four (4) files contained all the required documents per Title 22 regulations. During the course of staff record review licensee and staff provided additional documents from a sister facility or from licensee's phone and licensee was reminded of the need for complete employee records to be maintained on site at all time and a technical violation was issued. In addition, LPA advised Licensee to ensure all documents are signed and dated.

At approximately 2:00 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. Licensee states facility and residents' families work together to coordinate medical and dental appointments and residents' family coordinate transportation to and from visits. Facility does not manage cash resources for residents.

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.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC610 Emergency Disaster Plan (updated)
  • LIC500 Personnel Report (updated)
  • LIC308 Designation of Responsibility (for any changes)
  • Updated Proof of Liability Insurance
This report was reviewed with Licensee Charmaine Mendnaros and Appeal rights were given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/25/2025 03:17 PM - It Cannot Be Edited


Created By: Star Stevenson On 09/25/2025 at 02:29 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 4
FACILITY NUMBER: 486804180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

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 four (4) out of five (5) staff members which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Licensee agrees to read read regulation 87412(a)(13)(B), as well as provide proof (screen shot of access into Guardian website) by 09/27/2025, as well as, state in writing, they will not allow employees to work/enter Aging in the Bay 4 until an employee is associated on Guardian.
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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


LIC809 (FAS) - (06/04)
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