486804341-12-26-2025-21-AS-ADEZ-DPQTPS-20251226135450

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804341
Report Date: 12/26/2025
Date Signed: 12/26/2025 01:55:13 PM

Document Has Been Signed on 12/26/2025 01:55 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:	PER-ALTA CARE HOME		FACILITY NUMBER:	486804341
ADMINISTRATOR/ DIRECTOR:	ADRIENTE, DELILAH		FACILITY TYPE:	740
ADDRESS:	3113 PEBBLE BEACH DR.		TELEPHONE:	(707) 718-0498
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY: 6		CENSUS: 4	DATE:	12/26/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Applicant, Delilah Adriente		TIME VISIT/ INSPECTION COMPLETED:	02:30 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	On 12/26/2025 at approximately 12:00PM Licensing Program Analyst (LPA) Ali Deniz conducted a pre-licensing inspection and was greeted by Applicant, Delilah Adriente. This pre-licensing change of ownership (CHOW) inspection for a Residential Care Facility for the Elderly (RCFE) is being conducted for a single-story home with 4 resident rooms, 2 bathrooms, 1 staff room, and common areas. Facility received an approved fire clearance that allows for the total capacity of 6 residents, which 3 of 6 can be non-ambulatory and has hospice waiver for two residents. The facility currently has 4 clients in care at the time of this visit. LPA and applicant toured the indoor and outdoor portions of the facility. Facility was found to be clean and at a comfortable temperature. Outdoor patio furniture accessible for resident use. All resident bedrooms were found to be in clean and good repair. All had required chair, chest drawer and beds were made with appropriate linens. Restrooms had grab bars and lacked bath mats. LPA observed there to be emergency food and emergency water supply. Facility had enough emergency food and supply to operate more than 72 hours in an emergency. There were canned goods and non-perishable foods in pantry. Refrigerator and freezer were functioning and operational. LPA observed meats in freezer have expiration dates. LPA had conversation with applicant that all food in freezer must be labeled with expiration dated noted. 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 number of extra linens, towels, hygiene products and first aid kit. Facility has accessible and functioning phone for residents to communicate. Continued to 809C....

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2025

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: PER-ALTA CARE HOME	FACILITY NUMBER: 486804341
	VISIT DATE: 12/26/2025

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LPA observed fire extinguisher charged and last inspected on 12/22/2025. Fire alarm and carbon monoxide alarms were tested and operational. Signal system on all doors leading out of facility were on, tested and found operational. Water was measured in faucets used by residents and was found to be within regulation between 105&120 degrees F.

Medication is locked and inaccessible to residents and centrally stored.LPA spoke with admin that all medication must be kept in its original containers and cannot be pre-poured.

LPA observed the required postings including emergency disaster plan, the Let Us Know Complaint poster and See Something Say Something poster.

RCFE Component III was reviewed with Applicant.

No Deficiencies or Advisories given during visit.

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

Exit interview conducted. Copy of report discussed and provided to Applicant. The signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2025

LIC809 (FAS) - (06/04)

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