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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804203
Report Date: 03/06/2026
Date Signed: 03/06/2026 02:39:55 PM

Document Has Been Signed on 03/06/2026 02:39 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:SUNSHINE PETALUMA CARE HOMEFACILITY NUMBER:
496804203
ADMINISTRATOR/
DIRECTOR:		WHITE, DIANA CAROLINAFACILITY TYPE:
740
ADDRESS:804 ELY SOUTH BLVDTELEPHONE:
(707) 364-7247
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 5DATE:
03/06/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:17 PM
MET WITH:Roxana Galo (Licensee)TIME VISIT/
INSPECTION COMPLETED:
02:54 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management inspection to following up on a self-reported incident submitted to Community Care Licensing and met with Roxana Galo, Licensee. The purpose of this case management inspection is to obtain additional information regarding incident involving resident (R1). LPA reviewed records and conducted interviews.

Per incident report submitted 3/2/2026 reporting R1 had an un-witnessed fall on 2/26/2026. Licensee found R1 in the living room laying down at their left side R1 was bleeding from their head. At 5:00pm, R1’s responsible party arrived at the facility, helped them, checked them, decided not to call 911 and R1 remained in facility. During today’s visit, LPA reviewed R1's physician report dated 8/28/25 and care plan dated 11/22/25 which both do not indicate fall risk, but indicates that R1 had motor impairment left sided weakness due to a history of stroke. According to Licensee, the day of the incident, R1 sustained a small cut, triangle shape in their head, R1's responsible party arrived while the Licensee was assisting R1 after the un-witness fall happened, and R1's responsible party cut R1's hair near the area of the bleeding and applied vaseline, but they declined to call 911. R1's responsible party told the Licensee that they were taking responsibility and willing to sign any documentation certifying that they refused to take R1 to get medical assistance. As of today, R1's physician has not been contacted to notify them about R1's un-witnessed fall. LPA have a conversation with the Licensee about the requirement to follow up their facility plan of operation and regulation 87465 (a)(2) regarding providing medical assistance to a resident after a fall, hit head and bleeding observed.
Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given. Exit interview with Licensee 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: 03/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2026
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 03/06/2026 02:39 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/06/2026 at 02:11 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: SUNSHINE PETALUMA CARE HOME
FACILITY NUMBER: 496804203

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2026
Section Cited
CCR
87465(a)(2)

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87465 (a)(2) Incidental Medical and Dental Care - The licensee shall provide assistance in meeting necessary medical and dental needs...This requirement has not been met as evidenced by:
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Licensee agrees to contact R1's physician to report the incident and will submit self-certification that regulations 87465 Incidental Medical and Dental Care have been reviewed with facility staff and are understood to CCL by POC due date 3/13/2026.
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Based on LPA's records review and interview with the Licensee, the facility failed to seek timely medical after R1 had an unwitnessed fall on 2/26/2026, as of today the unwitnessed fall hve not been reported to R1's physician for follow up, which is an immediate risk to the health and safety of the resident.
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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: 03/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2026


LIC809 (FAS) - (06/04)
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