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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804266
Report Date: 08/15/2025
Date Signed: 08/15/2025 11:12:58 AM

Document Has Been Signed on 08/15/2025 11:12 AM - 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:ALL HEARTS CONNECT CARE HOMEFACILITY NUMBER:
486804266
ADMINISTRATOR/
DIRECTOR:		CASTOR, PRINCESSFACILITY TYPE:
740
ADDRESS:749 TEDDER DRIVETELEPHONE:
(415) 827-2185
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 0DATE:
08/15/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:06 AM
MET WITH:Princess Castor-Administrator TIME VISIT/
INSPECTION COMPLETED:
11:27 AM
NARRATIVE
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At approximately 10:00am Licensing Program Analyst (LPA) Contreras and Coppo arrived for a scheduled pre-licensing visit and met with administrator (admin) Princess Castor. This pre-licensing inspection is for a Residential Facility for the Elderly being conducted for a one story, 4 bedroom, 2 bathroom
home with a fire clearance approved for capacity of 6 non-ambulatory residents and a waiver granted for 3 hospice residents.

LPAs and admin toured the indoor and outdoor portions of the facility. Facility was found to be clean and at a comfortable temperature. Facility contained all required postings. Emergency exits clear and free from obstruction. Outdoor area has patio table and chairs accessible for resident use. Large divet on both perimeter sides of the yard were observed. LPAs had conversation with admin that they must cover or fill divet as it can present as a tripping hazard. Wheelchair ramp placed in front and back door leading to outsides.

4 of 4 bedrooms found in clean and good repair. Two shared rooms. All had required chair, chest drawer and beds were made with appropriate linens. Restrooms had grab bars and bath mats. LPA observed there to be emergency food and emergency water supply. There were canned goods and non-perishable foods in pantry. Refrigerator and freezer were functioning and operational. LPAs observed there to be a lock on refrigerator door. LPAs had conversation with admin that refrigerators cannot be locked and need to be accessible for residents. Admin to remove lock before resident move-in. LPA observed there to be plates and utensils including additional kitchenware. All cleaning products, sharp items, other toxins and chemicals are locked and inaccessible for residents. There are an ample amount of extra linens, towels, and hygiene products that are kept in storage closet.

LPA observed fire extinguisher charged.Fire alarm and carbon monoxide alarms were tested and operational. Signal system on all doors and windows leading out of facility were tested and found operational. Water was measured at 112,114.6 and 110.7 degrees F in faucets used by clients which is within regulation between 105 & 120 degrees F.

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NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2025
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 3
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: ALL HEARTS CONNECT CARE HOME
FACILITY NUMBER: 486804266
VISIT DATE: 08/15/2025
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Component III orientation was conducted with the Applicant

No Deficiencies or Advisories given during visit.

Pre-Licensing completed. Facility is ready to be Licensed as a Residential Facility for the Elderly. LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicants of Status.

Copy of report discussed and provided to Applicants. Exit interview conducted.
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
LIC809 (FAS) - (06/04)
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