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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804055
Report Date: 04/22/2025
Date Signed: 04/22/2025 03:17:12 PM

Document Has Been Signed on 04/22/2025 03:17 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:ALTA CARE HOMEFACILITY NUMBER:
496804055
ADMINISTRATOR/
DIRECTOR:		MONTE, ARMELA MARIEFACILITY TYPE:
740
ADDRESS:96 ALTA DRIVETELEPHONE:
(707) 508-7634
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 5DATE:
04/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Armelia Monte, Administrator & Laarni Lockerbie, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required inspection and met with Licensee, Laarni Lockerbie & Administrator, Armela Marie Monte. Facility is single story with 5 bedrooms & 3 bathrooms with an approved Fire clearance for 6 Non-Ambulatory residents & Hospice Waiver for 2. There is a total of 5 residents, 1 under hospice care & 3 with diagnosis of dementia.

LPA initiated a tour of the facility at approximately 8:25 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. 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. Cleaning supplies and toxins observed in locked cabinets in garage & under kitchen sink not accessible to residents in care. Resident’s rooms were furnished per regulation. Water temperature in bathrooms measured at 118 degrees F and 121.2 degrees F, not within the range of 105 to 120 degrees F allowed per regulation; although Administrator provided proof new water heater was just installed prior day and is adjusting (LIC9102 TA). Resident bathrooms had required slip resistant mats and grab bars. Extra hygiene products and linens were available. Cabinet containing cleaning supplies in garage was locked. There was enough lighting in all common areas, resident rooms, and hallways. Fire extinguisher was last inspected 3/4/2025. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational.

At approximately 9:15 AM, LPA reviewed 5 of 5 resident records and found 5 of 5 residents have current physician’s reports or care plans. 5 of 5 resident records contained current and signed admission agreements and physician’s orders on file. Continue on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
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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Document Has Been Signed on 04/22/2025 03:17 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/22/2025 at 12:27 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: ALTA CARE HOME
FACILITY NUMBER: 496804055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's interview with Administraotr of Annual record review, the licensee did not comply with the section cited above in 2 staff (S1 & S2) did not have the total 20 hrs of annual trainings but 12 in dementia, hospice, postual support, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Licensee/Administrator agrees to ensure that all staff (S1 & S2) obtain and complete staff required annual training-ensure all staff have required training. Submit proof of training to CCL by POC due date of 05/02/2025.
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:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
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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: ALTA CARE HOME
FACILITY NUMBER: 496804055
VISIT DATE: 04/22/2025
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Continue from LIC809:

Medication records are thorough and contained physician’s orders for each resident.

At approximately 10:30 AM, LPA review 4 of 4 staff records. 2 of 4 staff records (S1 & S2) only contained 12 of required 20 annual completed training as required (see LIC809D). Evidence of current first aid and CPR training were observed. 4 out of 4 staff have required Health Screening records.

Medications were centrally stored in locked cabinet in the facility living room. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 4/22/2025 at 12:30 PM.



At approximately 12:45 PM, LPA reviewed the facility emergency disaster plan with staff. Facility does not have a generator to supply power during an outage. Administrator informed they are currently deciding how to handle emergency outages with residents on oxygen and other electrical issues (see LIC9102 TA) The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts disaster drills quarterly and documented last disaster drill on 2/24/2025. Administrator Certification for Armela Marie Monte #6071239740 expires 07/08/2026.

Appeal Rights Given.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided.

LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 4/30/2025:

LIC 308 Designation of Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changes)
LIC 9020 Register of Facility /Resident’s
Copy of Lease Agreement
Proof of Liability Insurance
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
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