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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803595
Report Date: 10/14/2025
Date Signed: 10/14/2025 05:00:26 PM

Document Has Been Signed on 10/14/2025 05:00 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:CARRIAGE HOUSEFACILITY NUMBER:
496803595
ADMINISTRATOR/
DIRECTOR:		BLANCAFLOR, JOSEPHINEFACILITY TYPE:
740
ADDRESS:5695 CARRIAGE LANETELEPHONE:
(707) 303-7159
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 6DATE:
10/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Josephine Blancaflor-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Alviso conducted a Required - 1 Year inspection and met with live-in caregiver Melanie Taningco. A second caregiver, Brian, was also observed to be working during the inspection. Administrator Josephine Blancaflor was contacted, and arrived within the hour to meet with the LPA.

There were six (6) residents in care during the LPA's inspection. Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Facility has a required infection control plan. Facility has a required emergency disaster plan.

Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden approval (room #1 only). Fire extinguishers (2) were serviced and tagged as required. Facility has a hard wired smoke alarm system, which also has carbon monoxide check. The alarm system was put into test mode to check that it was working properly during the inspection. All exits were free and clear of obstructions. The backyard self latching fire exit gate opened freely, as required.

Emergency disaster drills are being conducted quarterly as required; Last drill was conducted with facility staff on 9/3/25.

The LPA reviewed six (6) resident files, resident medication records, and medication storage, including refrigerated medications. All files had required documentation.

The LPA reviewed five (5) staff files. All staff had criminal record clearance as required. All staff had required first aid certification, and CPR certification, as required. All staff annual training was reviewed during the inspection.

Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CARRIAGE HOUSE
FACILITY NUMBER: 496803595
VISIT DATE: 10/14/2025
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LPA toured the facility with caregiver Brian and the Administrator. Hot water was 107.4 degrees Fahrenheit, which is within regulation. Facility was clean and orderly. Food supply was sufficient with both perishable and non-perishable foods. Resident rooms, bathrooms, hallways, and common areas had sufficient lighting for residents in care.

The facility was at a comfortable temperature during the inspection. There was a sufficient supply of hygiene products, linens, cleaners/disinfectants, personal protective equipment (PPE), and paper products. All bathrooms had grab bars, and shower had non-slip mat for residents' use.

All disinfectants/cleaners were locked and inaccessible to residents in care. All medications were locked and inaccessible to residents in care. LPA observed all utilities to be working appropriately, and available for use as required for facility operations.

LPA observed the following deficiency:
Per LPA's record reviews, R5 is diabetic, and needs insulin injections, per medical assessment dated 8/12/25. R5 has a one touch blood- glucose meter on that reads blood glucose levels. Per interview with staff S1, R5 does own insulin injection. Per medical assessment, R5 is not able to provide own injections or handle own medications; There is no Dr's Order that R5 is able to provide own injections or self inject the insulin KwikPen as needed. This deficiency will be cited, 87629(a) Injections - The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional, see LIC809D.

Deficiencies 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.

Appeal rights provided to the Administrator.
Exit interview conducted with Licensee/Administrator Josephine Blancaflor.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2025 05:00 PM - It Cannot Be Edited


Created By: Dina Alviso On 10/14/2025 at 03:57 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: CARRIAGE HOUSE
FACILITY NUMBER: 496803595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87629(a)
87629(a) Injections - The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA's record reviews, R5 is diabetic, and needs insulin injections, per medical assessment of 8/12/25, and medication records, R5 has a meter that reads blood-glucose levels. Per interview with staff S1, R5 does own insulin injections 3xs a day. Per medical assessment, R5 is not able to provide own injections or handle own medications; There is no Dr's Order that R5 is able to provide own injections or self inject the insulin KwikPen as needed, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2025
Plan of Correction
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Licensee/Administrator to ensure they obtain a written, dated, and signed Dr's Order that R5 can handle and provide their own insulin injections as needed. POC due 10/15/25.
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:
Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2025


LIC809 (FAS) - (06/04)
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