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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803544
Report Date: 08/26/2025
Date Signed: 08/27/2025 08:15:38 AM

Document Has Been Signed on 08/27/2025 08:15 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:LITTLE BIRD ASSISTED LIVINGFACILITY NUMBER:
496803544
ADMINISTRATOR/
DIRECTOR:		FRANCO, KATIEFACILITY TYPE:
740
ADDRESS:511 WEBSTER STREETTELEPHONE:
(707) 559-5793
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY: 6CENSUS: 6DATE:
08/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Katie Franco, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required inspection and was greeted by staff who contacted Administrator Katie Franco, that arrived shortly after. Facility is a two story building only licensed on first story. There is 6 beds and 7 bathrooms in this residential care facility for the elderly that has a fire clearance for 6 Non-ambulatory of which 2 may be bedridden. Facility also has a hospice waiver approved for 3. At today’s inspection there were 6 residents in care with 2 have dementia diagnosis & 2 on hospice.

LPA initiated a tour of the facility around 10am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Exits were equipped with auditory devices which were activated and working properly at the time of the visit. Resident rooms were furnished per regulation. Water temperature in 3 of 7 bathrooms tested used by residents measured between 118 and 119.5 degrees F, with in range of 105 to 120 degrees F allowed per regulation. Bathrooms were equipped with necessary grab bars, and slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored. Emergency food and water supplies are stored in the garage along with Personal Protective Equipment.

Fire extinguishers were last serviced 6/4/2025. Smoke and Carbon Monoxide detectors located throughout the facility were operational during inspection. Disaster drills are conducted quarterly with most recent fire/disaster drill conducted 7/16/2025.
Continue on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2025
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: LITTLE BIRD ASSISTED LIVING
FACILITY NUMBER: 496803544
VISIT DATE: 08/26/2025
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Continued from LIC809

At approximately 11:30am on 8/26/2025 6 residents and 4 staff files were reviewed. LPA reviewed resident’s files and learned that 6 of 6 residents have an updated reappraisal/needs & care plan, TB and physician’s assessments on file as required by Title 22 Regulation.

LPA reviewed a sample of 4 staff records at 1:10pm on 8/26/2025 and learned that all facility staff present and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff at the facility have completed required annual trainings. LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed. Administrative Certificate for Katie Franco #7005297740 expires 1/28/2027. Medications and medication records (Centrally stored) were reviewed.

LPA obtained while at facility- LIC500, LIC9020, Admin cert., LLC documentation, &
Copy of Liability Insurance

Licensee/Administrator to submit updates of the following documents by 9/9/2025:



Control of Property Grant Deed
& updated LLC documents

No deficiencies cited during this inspection Exit interview conducted with Administrator/licensee
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
LIC809 (FAS) - (06/04)
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