486804219-4-7-2026-21-AS-SSTN-DSWT9L-20260407143207

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804219
Report Date: 04/07/2026
Date Signed: 04/07/2026 02:32:14 PM

Document Has Been Signed on 04/07/2026 02:32 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:	VIEWMONT COTTAGE		FACILITY NUMBER:	486804219
ADMINISTRATOR/ DIRECTOR:	SIMI, ANGELINA		FACILITY TYPE:	740
ADDRESS:	219 CORKWOOD STREET		TELEPHONE:	(707) 287-0118
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY: 6		CENSUS: 0	DATE:	04/07/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Licensee - Denise O'Reilly		TIME VISIT/ INSPECTION COMPLETED:	02:40 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 12:45 PM Licensing Program Analyst (LPA) Stevenson arrived to conducted a Annual Required inspection. There are currently no residents in care. Facility is approved/cleared for 6 non-ambulatory residents, one of whom could be bedridden. Facility has a hospice waiver for 6. Facility hasn't had any residents in care since February 2025. LPA met with Licensee Denise O'Reilly who is in the process of becoming the Administrator of Record. Facility is a two-story building with a large bonus room upstairs that will not be used by residents. LPA and licensee toured the building and grounds. All rooms were furnished per regulation. All rooms were in good repair. Extra linens were available. Water temperature in sinks were measured within the range of 105 to 120 degrees F. Fire extinguishers were charged and last tested May 2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose a risk if available to residents were located in the laundry room and under the kitchen sink and found to be secured. Facility has well constructed ramps in the front and back, as well as, shade and sun areas for residents to use. Facility is noted to have several televisions, and access to games, and a sunny exercises room. A staff bathroom off the kitchen is noted to enter into a Resident's private room and licensee is advised to keep the door locked between this bathroom and private Resident room. Licensee is asked to place signs on the door banning staff from entering that staff bathroom from the private resident bedroom, as well as, using that staff bathroom door to enter the private bedroom to ensure privacy for residents in care at all times. Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026

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: VIEWMONT COTTAGE	FACILITY NUMBER: 486804219
	VISIT DATE: 04/07/2026

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Continued from LIC809

LPA toured outside activity room and garage and found tools and toxins that could pose a risk to future residents were either secured or could be secured.

No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 05/06/2026:

1)Updated Liability Insurance
2) Updated LIC610E (if changes)

Exit interview conducted with licensee and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC809 (FAS) - (06/04)

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