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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801225
Report Date: 02/12/2026
Date Signed: 02/12/2026 03:09:18 PM

Document Has Been Signed on 02/12/2026 03:09 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:VICTORIA'S PLACEFACILITY NUMBER:
496801225
ADMINISTRATOR/
DIRECTOR:		GREGOIRE, AZENETHFACILITY TYPE:
740
ADDRESS:2300 DONAHUE AVE.TELEPHONE:
(707) 843-0341
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 5DATE:
02/12/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:04 PM
MET WITH:Azanethe Gregoire (Administrator)TIME VISIT/
INSPECTION COMPLETED:
03:23 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted a case management visit to cite deficiencies discovered during a complaint investigation and met with Azenethe Gregoire, Administrator.

LPA learned through records review and interviews with Licensee the facility has failed to obtain an updated physician’s report (LIC602) and care plan for resident (R1) after they have a significant change of condition and ambulatory status. According to R1’s physician’s report (LIC602) dated 12/4/22, R1 had a diagnosis of dementia, they were ambulatory, they did not have a history of skin breakdown and did not require reposition. However, medical records obtained by the Department revealed that R1 was bed-bound and receiving home health services for wound care since September 2, 2025. Although R1 clearly had a change of condition and ambulatory status requiring repositioning of the resident due to bed-bound status, the facility did not obtain an updated physician report and care plan. Furthermore, R1’s medical records revealed that on 9/10/25, R1 was transported to the emergency room with acute severe ankle problem due to a fall while they were getting out of the bath and fell twisting the left ankle, it was unclear in the after visit summary if R1’s was still ambulatory or not, but LPA reviewed incident report logs for this facility and the fall nor the hospitalization was not reported to the Department as stated in regulations. On 12/18/25 at approximate 8:56am, Licensee contacted LPA to notify the Department that R1 passed away while in the hospital after two days hospitalized. LPA inquired about reporting requirement regulation, but Licensee stated that they have mailed the required death report, but LPA did not receive it until 1/2/26.

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 Administrator and copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2026
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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Document Has Been Signed on 02/12/2026 03:09 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 02/12/2026 at 02:22 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: VICTORIA'S PLACE
FACILITY NUMBER: 496801225

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2026
Section Cited
CCR
87211(a)(2)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports.: (2) Occurrences, such as...major accidents which threaten the welfare, safety or health of residents..., shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidence by:
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Licensee agrees to review reporting requirements regulation, conduct training with all staff about reporting requirements, and will submit a written policy about the process that staff will follow to ensure that incidents are reported timely to CCL as proof of correction to clear the deficiency by POC due date.
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Based on LPA’s records review and interviews with the Licensee, the facility failed to notify the Department about R1’s hospitalization on 9/10/25 and R1’s death on 10/31/25, which could pose a potential risk to the health and safety of residents in care.
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Type B
02/27/2026
Section Cited
CCR87463

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87463 Reappraisals (i) When there is significant change in condition, ...or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff...This requirement was not met as evidence by:
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Licensee agrees to review all residents’ care plans to ensure that any change of condition observed is documented and once every 12 months, whichever occurs first is notified to the residents’ responsible party, then the Licensee will submit a self-certification form (LIC9098) to CCL by POC due date to clear the deficiency.
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Based on LPA’s records review and interviews with the Licensee, the Licensee failed to update R1’s care after they had a significant change of condition, which poses a potential risk to the health and safety of the residents.
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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: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/12/2026 03:09 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 02/12/2026 at 02:26 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: VICTORIA'S PLACE
FACILITY NUMBER: 496801225

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2026
Section Cited
CCR
87466

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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental..., the licensee shall ensure that such changes are documented & brought to the attention of the resident's physician and the resident's responsible person, This requirement has not been met as evidence by:
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Licensee agrees to review all residents’ care plans to ensure that all the residents have updated medical assessments including any change of condition are documented and brought to the attention of the resident’s physician and resident’s responsible person. Licensee will submit self-certification form (LIC9098) that all residents have current medical assessments on file by POC due date.
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Based on LPA’s records review and interviews with the Licensee, LPA learned that Licensee failed to obtain an updated physician’s report (LIC602) for R1 after they have a significant change of condition and ambulatory status, which poses a potential risk to the health and safety of the residents in care.
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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: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2026


LIC809 (FAS) - (06/04)
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