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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801091
Report Date: 04/28/2026
Date Signed: 04/28/2026 11:38:35 AM

Document Has Been Signed on 04/28/2026 11:38 AM - 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:HANNA HOUSE SCENICFACILITY NUMBER:
496801091
ADMINISTRATOR/
DIRECTOR:		ADALBERTO OJEDA-MENDEZFACILITY TYPE:
740
ADDRESS:819 SCENICTELEPHONE:
(707) 586-3536
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6CENSUS: 5DATE:
04/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:46 AM
MET WITH:David Hanna (Licensee)TIME VISIT/
INSPECTION COMPLETED:
11:58 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Administrator Adalberto Ojeda and Licensee David Hanna arrived later. Annual fees are current. Required postings were observed. There are residents with dementia diagnosis.

LPA/Administrator initiated a tour of the facility at 9:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathrooms measured at 112.1 and 113.4 degrees F which are not within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cabinet located in the locked garage and under the sink at the kitchen containing cleaning supplies was locked. Medications were centrally stored and locked. The facility has at least two days of perishable, and has one week of non-perishable foods. Facility has emergency food to operate for more than 72 hours during an emergency. Fire extinguisher was last inspected June, 2025. Smoke detectors located throughout the facility were tested and operational. Carbon monoxide detector was tested and operational. Exit doors have auditory alert system that were functional at time of visit. Last disaster drill was conducted on November 2025.

Continues on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2026
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HANNA HOUSE SCENIC
FACILITY NUMBER: 496801091
VISIT DATE: 04/28/2026
NARRATIVE
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Continued from LIC809...
LPA initiated file review at 9:30 am. Three staff files and five resident files were reviewed. All residents have current medical assessments and care plans. Staff have required First Aid and CPR certificates and completed annual required training hours. Administrator Certificate for Administrator Adalberto Ojeda, 7010339740, expires on 5/10/26. Medication and medication records reviewed.

The facility is a one story building and has an approved fire clearance dated April 11, 2007 that allows for six non-ambulatory residents and no bedridden resident. However, during records review one out five residents (R1) have a bedridden status and are occupying room #2 (R1), which is not cleared by the Fire Department as bedridden room. LPA/Licensee discussed the issue with R1 to provide the option to submit a request to the Fire Marshall to assess bedrooms to grant fire clearance, but according to the Licensee and LPA's observations R1 is not fully bedridden. During LPA's visit, R1 was observed in a wheelchair at the dining table eating breakfast, then they moved to the living room to watch tv and was transferred by staff to the recliner. Licensee agreed to obtain an updated physician report (LIC602) for R1.

Approximately at 10:15am, during file review, LPA noticed that R1 was hospitalized between 1/9/26 to 1/15/26, but a review of incident report logs revealed that incident was not reported to licensing agency. Also, resident (R2) was hospitalized between 3/26/26 to 3/30/26, but incident report was not submitted to the Department.

Licensee/Administrator agreed to submit updates of the following documents by 5/8/26: Personnel Report (LIC500) and a copy of liability insurance.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. 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: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/28/2026 11:38 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 04/28/2026 at 11:19 AM
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: HANNA HOUSE SCENIC
FACILITY NUMBER: 496801091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee's observation, interview and record review, the licensee did not comply with the section cited above in [two incident reports for residents' (R1 & R2) hospitalizations were not submitted to CCL which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2026
Plan of Correction
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Licensee agrees to review regulation and will submit self-certification form (LIC9098) and incident reports regarding two residents' (R1 & R2) hospitalizations by POC due date 5/12/26.
Type B
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee's observation, interview and record review, the licensee did not comply with the section cited above in one out of five residents (R1) was listed as bedridden when they are not fully bedridden which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2026
Plan of Correction
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Licensee agrees to contact R1's physician to obtain an updated physician report and will submit self-certification form (LIC9098) that they have obtained updated LIC 602 or letter from R1's physician clarifying their ambulatory status by POC due date 5/12/26.
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:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/28/2026 11:38 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 04/28/2026 at 11:19 AM
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: HANNA HOUSE SCENIC
FACILITY NUMBER: 496801091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2026

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
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above by not conducting disaster drill quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2026
Plan of Correction
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Licensee agrees to conduct a disaster drill every quarterly and will submit self-certification form (LIC9098) that they have reviewed regulation and conducted quarterly disaster drill by POC due date 5/12/26.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2026


LIC809 (FAS) - (06/04)
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