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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804133
Report Date: 07/31/2025
Date Signed: 07/31/2025 03:32:25 PM

Document Has Been Signed on 07/31/2025 03:32 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:RINCON VALLEY ASSISTED LIVING LLCFACILITY NUMBER:
496804133
ADMINISTRATOR/
DIRECTOR:		GURJA, FIKREFACILITY TYPE:
740
ADDRESS:996 ESTES DR.TELEPHONE:
(707) 235-8007
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 2DATE:
07/31/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:01 AM
MET WITH:Fikre Gurja, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:46 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Fikre Gurja arrived later, certificate #7029598740 expires 1/7/27. Facility roster was reviewed.

At approximately 9:30am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Most food was found to be stored in a safe manner with open items covered, some items such as applesauce and spaghetti sauce were opened without opened dates present. Kitchen cabinet under sink was locked. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. Resident room #1 smelled of urine, noticeable when entering the facility. LPA advised of regulation for Managed Incontinence 87625. LPA advised that residents must be kept clean and dry and also their bedding must be kept clean and dry. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 115 degrees F in the kitchen and 114.5 degrees F in the hall bathroom which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 6/19/24. LPA discussed with Admin that fire extinguishers need to be serviced annually. However, fire extinguisher showing as fully charged. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drills were conducted with each staff member in May and June of 2025, LPA observed all training dates for respective staff were within the quarter. Facility has a backup generator for use during a power outage.

Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2025
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.

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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: RINCON VALLEY ASSISTED LIVING LLC
FACILITY NUMBER: 496804133
VISIT DATE: 07/31/2025
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Continued from 809...

Facility's backyard perimeter fence in disrepair in several places but primarily on the back and right hand side (if facing the backyard). Planks are loose, have fallen, are missing, have nails exposed, and have an appearance of dry rot. Backyard also has pile of discarded chairs and other items for disposal piled up on side of shed. Ramp on right hand side of facility has lifting boards needing repair. LPA and Admin discussed repairing the fence such that it is sturdy and safe. Admin advised he is waiting for trash pile to be picked up by the City of Santa Rosa. LPA advised Admin can also take to the dump, if city is taking an extended period of time.



At approximately 11:00am LPA conducted a review of two [2] resident records. LPA observed resident (R1) in room #1 to have full bed rails. Per Admin, R1 was on hospice beginning 12/30/24 but graduated from hospice on 6/27/25. LPA advised that full bed rails are a prohibited condition unless resident is on hospice and has a hospice care plan that specifies the need for full bed rails. LPA reviewed hospice care plan, plan does not indicate the need for full bed rails (deficiency cited, see 809D). Per R1 physician's report and per Admin, R1 is bedridden. LPA advised facility does not have fire clearance for bedridden residents. Admin showed LPA form filled out for Santa Rosa Fire Dept (SRFD) indicating R1 was using oxygen and Admin checked a box for bed bound on the form, however fax transmission to Fire Dept not produced for LPA. Admin did produce email sent to SRFD notifying them that R1 was using oxygen, but nothing noted about bed bound or bedridden status (deficiency cited, see 809D). LPA reviewed R1's appraisal. Per, Admin, resident appraisal are completed by residents' responsible parties. LPA discussed with Admin that he needs to complete the appraisals. LPA discussed with Admin that it is good practice to complete the appraisal himself, this will allow him to determine if a potential resident is compatible with other residents and/or if facility staff will be able to meet the care needs of resident, among other valuable uses.

Resident's (R2's) physician report shows faxed dated of 8/1/24, is missing diagnosis and missing physician signature and date. LPA advised Admin to be sure to review residents' physician reports/medical assessments once received in order to review changes in ambulatory status and diagnoses, as well as making sure it is signed and dated. LPA also advised that a medical assessment must be completed

Continued on 809C(2)...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: RINCON VALLEY ASSISTED LIVING LLC
FACILITY NUMBER: 496804133
VISIT DATE: 07/31/2025
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annually, regardless of diagnosis, per regulation 87463(h). Most current appraisal for R2 completed 2022 (deficiency cited, see 809D).


At approximately 12:30pm LPA conducted review of five [5] staff records. LPA discussed with Admin Health and Safety Code (HSC) 1569.625 (b)(1) and (2) and HSC 1569.625(c). LPA advised of subject matters to be covered in training.


At approximately 2:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. LPA went over the requirement to keep a PRN MAR/log that meets the requirements of regulation 87465.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
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 Administrator. 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: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/31/2025 03:32 PM - It Cannot Be Edited


Created By: Christi Coppo On 07/31/2025 at 02:53 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: RINCON VALLEY ASSISTED LIVING LLC
FACILITY NUMBER: 496804133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2025

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 and Admin interview and record review, the licensee did not comply with the section cited above in that R2's most recent appriasal dated 2022, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2025
Plan of Correction
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Admin to submit compelted appraisal for R2 by plan of correction due date. Appraisal to be signed by responsible party.
Type B
Section Cited
CCR
87606(b)
Care of Bedridden Residents
(b) A licensee shall notify the fire authority having jurisdiction within 48 hours of accepting or retaining any person who is bedridden, as specified in Health and Safety Code section 1569.72.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and interview and record review, the licensee did not comply with the section cited above in that R1 is bedridden but facility does not have bedridden clearance, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
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Admin to notify local fire department of R1's bedridden status and obtain fire clearance for at least one bedridden resident. Admin to submit proof of notification to local fire department by plan of correction due date. If fire clearance is not obtained Admin to notify CCL immediately.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/31/2025 03:32 PM - It Cannot Be Edited


Created By: Christi Coppo On 07/31/2025 at 02:53 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: RINCON VALLEY ASSISTED LIVING LLC
FACILITY NUMBER: 496804133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and interview and record review, the licensee did not comply with the section cited above in that R1 not on hospice and full bed rails present, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2025
Plan of Correction
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Facility immedately removed full rails from R1's bed while LPA present. Deficiency cleared.
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
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