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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800304
Report Date: 04/14/2026
Date Signed: 04/14/2026 06:55:15 PM

Document Has Been Signed on 04/14/2026 06:55 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: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:
04/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Ladana Luellen, licenseeTIME VISIT/
INSPECTION COMPLETED:
07:14 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by licensee Ladana Luellen. Administrator certificate #7004459740 expired 4/10/26. However, licensee produced proof of mailing of Admin cert renewal with date stamp of 4/11/26. Facility currently has three (3) residents in care two (2) of which are currently on hospice.

At approximately 2:15pm LPA toured the building and grounds. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be open, uncovered, and many items expired. Facility has a pantry in room #3 and food pantry in the kitchen. LPA observed expired food items in both. Expired items include: two 920 boxes of Stove Top expired 9/2/2022, two (2) boxes of Shake and Bake expired 2/9/2016, Betty Crocker Mashed potatoes expired 3/15/2015, sunflower seeds expired 3/4/2019, Jello pudding expired 7/16/2023, Jello gelatin expired 1/19/2019, Mrs. Grass noodles soup expired 8/9/2022, boiled oysters 7/4/2017, sardines expired 12/2024, luncheon loaf expired 3/15/2020, corn muffin mix expired 11/3/2018, salad dressings respective expired 10/30/2024, 3/2022, and 12/22/2021 (deficiency cited, see 809D). Freezer item of sausage links and hot dogs were stored open and uncovered in kitchen. Facility also has a freezer in the garage, almost all items in the freezer had ice and ice crystals forming on top and within packages of meat and other items. Open and uncovered was a bag of meat that was fatty and gray in color. LPA observed in pantry in room #3 open bag of grits not sealed or rolled shut, and one container of spicy ranch salad dressing 7/12/2025 and strawberry fruit spread 6/8/2019 open, not refrigerated and stored in pantry closet (deficiency cited, see 809D). LPA observed kitchen cabinet under sink to contain bucket to catch water. Sink leaks, per licensee they have to empty the bucket of water once a month. Sink in room #1 has two (2) buckets underneath to catch water. LPA observed water in both buckets as well as bowed/ballooning wood and gray and blue substance

Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2026
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 17
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 17
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: WELL CARE HOME
FACILITY NUMBER: 496800304
VISIT DATE: 04/14/2026
NARRATIVE
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Continued from 809...

present. Facility has three bathrooms: one (1) in resident room #1, one (1) in resident room #3 and a main bathroom in the hallway. Main bathroom has electrical outlet is disrepair (deficiency cited, see 809D).Additionally, per licensee resident has been using bathroom in room #3, which is not their room. The bathroom is the first door on the right when entering room #3. LPA advised of regulation 87307(a)(2)(c) which states: No bedroom of a resident shall be used as a passageway to another room, bath or toilet.

All bedrooms were equipped with lighting, night stand, chair, but room #2 did not have chest of drawers (deficiency cited, see 809D). Window sill in room #3 has many dots of black and gray fuzzy substance (deficiency cited, see 809D). Extra hygiene products and linens were available. LPA discussed with licensee the use of resident rooms as storage for faclity supplies such a gauze, gloves, chucks, and personal items such as clothes. Room #1 has two large furniture items used to store the licensees' personal items. Additionally, LPA found closets in room #1 and room #3 to be locked, making them inaccessible to residents in care. Closet in room #3 also houses facility supplies. LPA discussed with licensee regulation 87308 pertaining to storage. Resident bathrooms had required bath mats and grab bars. Water temperature in sinks measured at 108.6 degrees F in the kitchen and 107.4 in the bathroom used by residents, both of which are within the allowable range of 105 to 120 degrees F. Facility has another bathroom used by staff only.

Fire extinguishers were last inspected 10/22/2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted on 1/25/26. Facility has a backup generator for use during a power outage.

At approximately 4:00pm LPA conducted a review of three (3) out of three (3) resident files. R1 did not have TB clearance file (deficiency cited, see 809D).

At approximately 4:30pm LPA conducted a review of three (3) staff files. Staff S1 and S2 did not have 1st Aid (deficiency cited, see 809D), Health Screen with TB clearance (deficiency cited, see 809D), or required training current or on file (deficiency cited, see 809D).

Continued on 809C(2)...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026
LIC809 (FAS) - (06/04)
Page: 3 of 17
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: WELL CARE HOME
FACILITY NUMBER: 496800304
VISIT DATE: 04/14/2026
NARRATIVE
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Continued from 809C...

At approximately 5:30pm LPA conducted a review of medication regulations including a PRN MAR requirement and Centrally Stored Medication Log requirements. Facility not using a PRN MAR. LPA discussed with licensee obtained PRN authorization letters for all residents in order to know if a PRN MAR is required for that resident.

LA discussed with licensee activities in the facility, especially those suited for residents with cognitive impairment or dementia. LPA did not observe any activities.

LPA and licensee discussed Emergency Disaster Plan. Licensee confirmed no updates needed.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance


Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026
LIC809 (FAS) - (06/04)
Page: 4 of 17
Document Has Been Signed on 04/14/2026 06:55 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/14/2026 at 06:05 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: 04/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)(2)(B)
Infection Control Requirements
(2) Environmental cleaning and disinfection activities shall be performed following the manufacturers'instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (B) Walls and window coverings in resident care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in window sill in room #3 has many dots of black and gray fuzzy substance,which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2026
Plan of Correction
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Facility to submit pictures of window sill free from black and gray fuzzy substances by plan of corerction due date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in Main bathroom has electrical outlet is disrepair. Sink in kitchen and in room #1 leaking, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2026
Plan of Correction
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Facility to submit work order for leaking sinks and submit pictures of repaired or replaced vanity cabnit in room #1 and picture of repaired electrial outlet in bathroom by plan of correction due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2026


LIC809 (FAS) - (06/04)
Page: 5 of 17
Document Has Been Signed on 04/14/2026 06:55 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/14/2026 at 06:05 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: 04/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(B)
Personal Accommodations and Services
(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation the licensee did not comply with the section cited above in that room #2 did not have chest of drawers for resident, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2026
Plan of Correction
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Facility to submit picture of chest of drawers present in room #2 by plan of correction due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2026


LIC809 (FAS) - (06/04)
Page: 6 of 17
Document Has Been Signed on 04/14/2026 06:55 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/14/2026 at 06:05 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: 04/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in that S1 and S2 did not have a Health Screen on file or TB clearance on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2026
Plan of Correction
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Facility to submit health screen with TB clearance for S1 and S2 by plan of correction due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2026


LIC809 (FAS) - (06/04)
Page: 7 of 17
Document Has Been Signed on 04/14/2026 06:55 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/14/2026 at 06:05 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: 04/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in that S1 and S2 did not have first aid on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2026
Plan of Correction
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2
3
4
Facility to submit proof of !st Aid certification for S1 and S2 by plan of correction due date.
Section Cited
Deficient Practice Statement
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2026


LIC809 (FAS) - (06/04)
Page: 8 of 17
Document Has Been Signed on 04/14/2026 06:55 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/14/2026 at 06:05 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: 04/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(a)(2)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in that S1 and S2 did not have the rewuried number of hours compelted for training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2026
Plan of Correction
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2
3
4
Facility to submit proof of completed training hours for S1 and S2 in the requierd duration and required subject matters by plan of correction due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2026


LIC809 (FAS) - (06/04)
Page: 9 of 17
Document Has Been Signed on 04/14/2026 06:55 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/14/2026 at 06:05 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: 04/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation], the licensee did not comply with the section cited above in that Food was found to be open, uncovered, and many items expired. Facility has a pantry in room #3 and food pantry in the kitchen. LPA observed expired food items in both. Expired items include: two 920 boxes of Stove Top expired 9/2/2022, two (2) boxes of Shake and Bake expired 2/9/2016, Betty Crocker Mashed potatoes expired 3/15/2015, sunflower seeds expired 3/4/2019, Jello pudding expired 7/16/2023, Jello gelatin expired 1/19/2019, Mrs. Grass noodles soup expired 8/9/2022, boiled oysters 7/4/2017, sardines expired 12/2024, luncheon loaf expired 3/15/2020, corn muffin mix expired 11/3/2018, salad dressings respective expired 10/30/2024, 3/2022, and 12/22/2021 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2026
Plan of Correction
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2
3
4
Facility to submit LIC9098 self-certifying they will immediately remove all expired food items from facility by plan of correction due date. Additionally, facility to submit picture of pantries.
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in that LPA observed in pantry in room #3 open bag of grits not sealed or rolled shut, and one container of spicy ranch salad dressing 7/12/2025 and strawberry fruit spread 6/8/2019 open, not refrigerated and stored in pantry closet, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2026
Plan of Correction
1
2
3
4
Facility to submit LIC9098 self-certifying they will store all food items appropriately and at the appropriate temperature by plan of correction due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2026


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Document Has Been Signed on 04/14/2026 06:55 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/14/2026 at 06:35 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: 04/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA, the licensee did not comply with the section cited above in that R1 did not have TB clearance on file poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2026
Plan of Correction
1
2
3
4
Facility to submit TB clearance for R1 by plan of correction due date.
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2026


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