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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804392
Report Date: 05/07/2026
Date Signed: 05/07/2026 02:38:32 PM

Document Has Been Signed on 05/07/2026 02:38 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 HOMEFACILITY NUMBER:
486804392
ADMINISTRATOR/
DIRECTOR:		WASONGA, AGRIPPINAFACILITY TYPE:
740
ADDRESS:5220 MAYRENE BATES LANETELEPHONE:
(707) 297-2797
CITY:FAIRFILEDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 0DATE:
05/07/2026
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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At approximately 1:05 PM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a post-licensing facility. The mother of licensee (S1) was present and licensee was called to advise of today's post-licensing inspection. Facility has received fire clearance for six residents including one (1) bedridden resident in room #4 and five (5) non-ambulatory residents, as well as, a hospice waiver for four (4) residents. Bedroom #1 by front door is approved from staff or only an ambulatory resident. Facility currently has no residents in care.

Facility is a single-story home with 4 bedrooms and 3 bathrooms, is spacious, a comfortable temperature and without odors. There is now a gentle ramp into the facility. Facility has required posters including Personal Rights, Non-Discrimination, Complaint/Ombudsman.

Facility now has a locking area for sharps storage and pantry. In addition laundry room and associated detergents can be locked. LPA recommends locking drawers under the kitchen sink to store dishwashing cleaning supplies. A cabinet door under the microwave will need to be repaired.

Water delivered from facets that will be accessible to residents measured 102F and not in the 105-120F range as required by title 22 regulations, licensee will need to turn up the temperature of the water heater a tiny amount, and water temperature logging is recommended in anticipation of their first resident.


Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2026
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: GRACEFUL TOUCH CARE HOME
FACILITY NUMBER: 486804392
VISIT DATE: 05/07/2026
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continued from LIC809
Two (2) of three (3) showers, all toilets and bathtubs now have grab bars installed, but a master bathroom shower will need a grab bar outside a bar soap holding area. Applicant was again advised to provide for locking bathroom cabinets below sinks if they intend on keeping cleaning supplies in each bathroom. In addition, applicant will need to increase lightening in bathroom sharing a wall with the garage in anticipation of accepting elderly residents with potentially decreased eyesight.

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.

Facility has two fire extinguishers that are found fully charged and last serviced June 2025. Smoke and carbon monoxide detectors are hardwired and in working order, however the battery of the detector in the front bedroom needs to be replaced. Facilities phone was tested and found operational.

Windows, doors, walls, ceilings, screens, paint, and furniture are in good condition.

Licensee is advised to remove tripping hazards in the back and side yards including reducing concrete lips, and removal of various items of wood and minor bits of pottery.

Facility now has a large first-aid kit that contains an American Red Cross 1st Aid manual.

Licensee is reminded of the requirements to ensure that hired staff have background checks and Guardian association as well as required documentation and that Residents have all the required documentation and a copy of the required documentation needed at each Residential Community for the Elderly (RCFE) was left in the facility (LIC311C), in addition licensee is reminded of the need to submit to Community Care Licensing, valid liability insurance once they accept their first resident in care.

No Deficiencies are being cited.

Report was reviewed with the mother of licensee.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026
LIC809 (FAS) - (06/04)
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