486804392-12-4-2025-21-AS-SSTN-DP2THT-20251204134517

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804392
Report Date: 12/04/2025
Date Signed: 12/04/2025 01:45:26 PM

Document Has Been Signed on 12/04/2025 01:45 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:	GRACEFUL TOUCH CARE HOME		FACILITY NUMBER:	486804392
ADMINISTRATOR/ DIRECTOR:	WASONGA, AGRIPPINA		FACILITY TYPE:	740
ADDRESS:	5220 MAYRENE BATES LANE		TELEPHONE:	(707) 297-2797
CITY:	FAIRFILED	STATE: CA	ZIP CODE:	94533
CAPACITY: 6		CENSUS: 0	DATE:	12/04/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Agrippina Wasonga-Applicant		TIME VISIT/ INSPECTION COMPLETED:	02:10 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 9:40 AM, Licensing Program Analyst (LPA) Star Stevenson arrived ANNOUNCED to conduct a Pre-licensing Facility Inspection with applicant. Facility has received fire clearance for six residents including one (1) bedridden resident in room #4 and 5 non-ambulatory residents. Bedroom #1 by front door is approved from staff or only an ambulatory resident. Facility is a single-story home with 4 bedrooms and 3 bathrooms. There are 5 small steps without railing to enter the house that present a tripping hazard and applicant has been asked to provide for a ramp or railing that meets code. Applicant will need to provide for separate locked storage outside of locking pantry. In addition applicant will need to provide for a secure area for sharps/knives, LPA recommends a locking drawer or keypad closet. Water delivered from facets accessible by residents measured 133F and not in the 105-120F range as required by title 22 regulations. Applicant is asked to submit a water temp log over 5 days to LPA. Each of the three showers and bathtub will need grab bars installed and each of three toilets will need grab bars install at their sides. The right sink in master bathroom will need to repaired to avoid leaks. Applicant was advised to provide for locking bathroom cabinets if they intend on keeping cleaning supplies in each bathroom. In addition, applicant will need to provide proof of increased lighting in hallway bathroom to serve elderly residents who my have eyesight difficulties. Medications stored above the refrigerator in unlocked cabinets will need to be locked and made more easily accessible. Kitchen appliances, utensils, and food preparation areas are in good condition. Applicant will need to provide for a seven day supply of non-perishable food, as well as two days of perishable foods once residents received. Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025

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: GRACEFUL TOUCH CARE HOME	FACILITY NUMBER: 486804392
	VISIT DATE: 12/04/2025

NARRATIVE

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Continued from LIC809
Facility has two fire extinguishers, one in the kitchen and the other in hallway were found fully charged and last serviced June 2025. Smoke and carbon monoxide detectors are hardwired and in working order. Windows, doors, walls, ceilings, screens, paint, and furniture are in good condition.

On the outside of the home, Applicant was asked to remove lock securing perimeter gate and applicant will need to fill in large in-ground jacuzzi or provide for secure fencing around the body of water.

Applicant will need to provide evidence of a larger first-aid kit that contains an American Red Cross 1st Aid manual, as well as, evidence of working dedicated facility phone and internet/video conferencing capabilities for residents in care.

Applicant will need to provide photographic or in-person proof of the following to move forward in the licensing process, applicant agrees to complete the following items by January 4th, 2026.

A ramp or railing to make 5 small entryway steps less of a tripping hazard.
Evidence of a standing grab bars in each of 3 showers and at bathroom tub in master bathroom.
Evidence of solid grab bars at each of the 3 facility toilets.
Evidence of outdoor jacuzzi filled in with concrete or other substrate or with perimeter fence.
Evidence of required posters (Personal Rights, Non-Discrimination, Complaint/Ombudsman posters) See PUB 475 available at www.ccld.ca.gov (minimum dimension of 20"x26")
Evidence of locking sharps/knives storage, locking laundry/toxin storage
Evidence of night lights in common hallways leading to bathrooms
Evidence of dedicated facility phone (phone bill or working phone number)
Evidence of first aid kit that includes 1st aid manual approved by American Red Cross
Evidence of repair of right master bathroom sink leak.
Applicant to submit a 5 day water temperature log to ensure water is between 105-120F.

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025

LIC809 (FAS) - (06/04)

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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: GRACEFUL TOUCH CARE HOME	FACILITY NUMBER: 486804392
	VISIT DATE: 12/04/2025

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 26 27 28 29 30 31 32	Continued from LIC809C Applicant could not provide evidence of Liability insurance at the time of this visit. Applicant will provide evidence of liability insurance to LPA by 01/04/2026. Upon receipt of repairs and updates, LPA will notify Central Application Bureau to issue license. Signature of Applicant acknowledges understanding

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025

LIC809 (FAS) - (06/04)

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