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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803924
Report Date: 10/01/2025
Date Signed: 10/01/2025 01:11:32 PM

Document Has Been Signed on 10/01/2025 01:11 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:SONOMA GROVEFACILITY NUMBER:
496803924
ADMINISTRATOR/
DIRECTOR:		ALEXANDER VARSHAVSKYFACILITY TYPE:
740
ADDRESS:765 DONALD STREETTELEPHONE:
(707) 996-2161
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY: 32CENSUS: 24DATE:
10/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Alex Varshavsky (Licensee)TIME VISIT/
INSPECTION COMPLETED:
01:53 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a required Annual inspection and met with Administrator/Licensee Alex Varshavsky. There are currently five residents receiving hospice services. Annual fees are current. Required postings observed.

At approximately 9:30am LPA/Administrator toured the building and grounds. The facility was found to be clean and common areas of facility was at comfortable temperature. LPA observed at least two-day supply of perishable and seven-day supply of non-perishable food. Food items were found to be stored and handle in a health and safe manner with open items were labeled with dates. All bedrooms were furnished per regulation. LPA inspected areas of concern from the last annual, items including night lamps, broken windows, fireplace screen, shower curtains and adequate bed springs were found within compliance. Extra hygiene products and linens were available. Resident bathrooms all had grab bars and mats were observed. Water temperature in sink accessible to residents in care in bathroom measured at 109.8 and 110.7 degrees F which is within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 10/23/2024. During the tour of the facility, LPA pulled the call alert pendant from a resident's room, then staff was alerted by the sound and arrived timely to assist resident. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired and serviced quarterly by Nemesis Fire, last serviced on 6/12/25. Facility’s last quarterly disaster drills were conducted 7/18/2025. Facility has a backup generator for use during a power outage. Auditory alarms were working properly. Activities and menu calendar were posted.
Continue on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2025
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: SONOMA GROVE
FACILITY NUMBER: 496803924
VISIT DATE: 10/01/2025
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Continued from LIC809...

LPA initiated file review at 10:10am of ten residents and six staff records. Two out of ten residents (R1 & R2) care plan was updated, but not signed by resident's responsible party. According to Licensee, their responsible parties are hard to get a hold of them, but LPA have advice the Licensee to document their attempts. All six staff have required CPR/1st aid certificates and 20 hours of annual training completed. LPA confirmed that the facility is using the department's approved vendor for training materials. Alex Varshavsky Administrator Certificate 7019479740 expires 7/15/2026.

At approximately 12:30pm LPA/Med Tech conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. LPA observed that the facility have implemented a system of adding start dates to bottles and list on Centrally Stored Medication Log as suggested as best practices by LPA.

Licensee agreed to submit updated copies of the following by not later than 10/15/25: LIC500- Personnel Report, LIC308- Designation of Responsibility and copy of 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 and discussed with Licensee. 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 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: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/01/2025 01:11 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 10/01/2025 at 12:57 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: SONOMA GROVE
FACILITY NUMBER: 496803924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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 in two out of ten residents (R1 & R2) care plans were updated, but not signed by their responsible party which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2025
Plan of Correction
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Licensee agrees to arrange a meeting with parties outlined in regulation 87463(a) and update appraisals for noted residents. Licensee will submit self certification that all appraisals have been updated per regulation 87463 by POC due date, 10/15/2025 to clear the citation.
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: 10/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2025


LIC809 (FAS) - (06/04)
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