<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800304
Report Date: 04/08/2025
Date Signed: 04/08/2025 04:14:00 PM

Document Has Been Signed on 04/08/2025 04:14 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WELL CARE HOMEFACILITY NUMBER:
496800304
ADMINISTRATOR/
DIRECTOR:		LUELLEN, LADANA B.FACILITY TYPE:
740
ADDRESS:538 MARIA DRIVETELEPHONE:
(707) 762-9296
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 5CENSUS: 3DATE:
04/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Ladana Luellen, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:30 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
License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual inspection visit of the facility. LPA was welcomed by Licensee/Administrator, Ladana Luellen. There is a total of 3 residents in care, 1 currently on Hospice, 3 with dementia.

LPA toured the facility on 4/8/2025 at 1:45 PM with Licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Fire extinguishers were last checked 10/14/2024. Hot water temperature measured between 111.3 degrees F and 112.6 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms while touring facility. Resident bathrooms had required slip resistant mats and grab bars. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the laundry room. Dangerous items were found stored inaccessible to residents with dementia. There was an ample supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. All bedrooms have lighting & appropriate furnishings. Medications were centrally stored in locked cabinet in facility office/kitchen.

A review of three (3) resident & two staff records as well as medication audit was conducted. LPA reviewed resident’s files at 2:15pm on 4/8/2025 and learned that all residents have an appraisal or updated re-appraisals/needs & care plan and 3 out of 3 residents physician’s assessments (LIC 602A) are updated as required by Title 22 Regulations on file.
Continue on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
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 5
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)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WELL CARE HOME
FACILITY NUMBER: 496800304
VISIT DATE: 04/08/2025
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 LIC809
Medications were centrally stored in locked cabinet in the facility kitchen. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 4/8/2025. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

LPA reviewed a sample of staff records at 2:45 PM on 4/8/2025 and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. LPA observed during staff file review that facility has proof on 4/8/2025 at 2:45 PM of direct care staff annual training requirements. LPA was presented with proof of CPR and 1st Aid certification for Licensee although staff does not have current 1st Aid. (see LIC 9102 Advisory Notes) Ladana Luellen Administrator Certificate # 7004450740 expires on 4/10/2026. Facility’s last recorded disaster drill was not recorded, licensee informed did not remember when, falling out of Title 22 Regulations (see LIC809-D).LPA advised to ensure that disaster drills are conducted quarterly in different shifts and log drill, as well review facility emergency plan to ensure accuracy according to the needs of facility residents.

Appeal of Rights Given.



The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided

LPA Hansen is requesting Licensee to update the following documents by 4/25/2025:



LIC 308 Designated (if changes)
LIC 500 Personnel Summary (if changes)
LIC 610 Emergency Disaster Plan (if changes)
LIC 9020 Register of Facility /Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/08/2025 04:14 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/08/2025 at 03:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WELL CARE HOME
FACILITY NUMBER: 496800304

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview with Licensee & unknown record review, the licensee did not comply with the section cited above in not conducting a disaster drill quarterly and or recording them, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
1
2
3
4
Licnesee to conduct and log disaster drill and send with LIC9098 Proof of correction and indicate they understand the regulation by POC due date 4/11/2025 to clear citation.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
Page: 5 of 5