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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804270
Report Date: 01/27/2026
Date Signed: 01/27/2026 04:22:21 PM

Document Has Been Signed on 01/27/2026 04:22 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:AILA CARE HOMEFACILITY NUMBER:
496804270
ADMINISTRATOR/
DIRECTOR:		MONTE, ARMELA MFACILITY TYPE:
740
ADDRESS:4766 FAIRWAY DRTELEPHONE:
(628) 259-2954
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 6CENSUS: 6DATE:
01/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Armela Monte-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit, on 1/27/26 at approximately 9:20am, and met with Administrator Armela Monte. LPA observed two caregivers on duty upon arrival. Licensee, Laarnie Lockerbie, arrived to the facility during the LPA's inspection.

Facility has an approved fire clearance for six (6) non-ambulatory residents. There are five (5) resident rooms, and one of them is a shared room. Facility has a required infection control plan. Facility has a required emergency disaster plan. Hospice waiver approved for two (2) residents'.

Per review of records, emergency disaster drills are being conducted; Last drill was conducted on 11/12/25, a fire drill. Fire extinguisher (1) was showing charged (showing green marker), and was tagged. All exits were free and clear from obstruction. All exits had auditory alarms. The carbon monoxide detector worked appropriately during the inspection. All smoke alarms worked appropriately during the inspection.
LPA reviewed six (6) resident files. All files were complete.
LPA reviewed five (5) staff files. All staff have criminal record clearance as required. All staff have first aid certification, and CPR certification. LPA reviewed staff training. Administrator certificate is current for Armela Monte-#6071239740, expires 7/8/26.

The Administrator, and the Licensee, toured the facility with the LPA. The food supply was sufficient. Sufficient supply of linens, hygiene products, cleaners/disinfectants, paper products, and personal protective equipment (PPE). The facility was at a comfortable temperature during the inspection. The facility had sufficient lighting throughout the home, in bathrooms, hallways, resident rooms, and in all common areas. Hot water was measured at 109.9 degrees Fahrenheit. There were grab bars, and mats for resident use. Disinfectants/cleaners were locked up and inaccessible to residents in care. All medications were locked and inaccessible to residents in care. The backyard had patio furniture, table and chairs, for residents' use. All walkways/pathways in the yard were free and clear of obstructions. The fire exit gate opened freely for use as needed/in an emergency.
Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: AILA CARE HOME
FACILITY NUMBER: 496804270
VISIT DATE: 01/27/2026
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LPA is requesting the following documents be updated and submitted by 2/27/26:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610D -Emergency Disaster Plan (9 pages)- review & update as needed- submit a copy if changes or submit copy of last page if no changes (signed/dated)
Copy of Current Liability Insurance
Infection Control Plan-review & update as needed- submit a copy if changes or submit copy of last page (signed/dated) if no changes.
Poster of Residents
Copy of current Administrator Certificate

LPA observed the following deficiencies:
Per LPA's records review, Resident R6 is identified by the Physician as bedridden/bed bound, and needing total care, per medical assessment dated 10/30/2025. The facility does not have a fire clearance bedridden approval to retain a bedridden resident.
This deficiency will be cited, 87202(a)(2) Fire Clearance- All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal, "bedridden persons", see LIC809D. Immediate Civil Penalty fine will be assessed in the amount of $500, see LIC421IM.

Per LPA's review of records, the medication training documentation had no count of hours/time spent for the staff's training. Administrator was not able to provide staff, S2, S3, S4, and S5’s, medication "initial hours" of training. This deficiency will be cited, 1569.69(a)(2) HSC Medication Training-In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment, 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.
Exit interview conducted with Administrator, Armela Monte; Appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/27/2026 04:22 PM - It Cannot Be Edited


Created By: Dina Alviso On 01/27/2026 at 03:38 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: AILA CARE HOME
FACILITY NUMBER: 496804270

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA's records review, Resident R6 is identified by the Physician as bedridden/bed bound, and needing total care, per medical assessment dated 10/30/2025. The facility does not have a fire clearance bedridden approval to retain a bedridden resident, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. Immediate Civil Penalty fine will be assessed in the amount of $500, see LIC421IM.
POC Due Date: 01/28/2026
Plan of Correction
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Licensee/Administrator to submit an updated application form LIC200 showing requested capacity of five nonambulatory and one bedridden. Submit a sketch with proposed capacity, showing the capacity and facility floor/layout. Ia fee of $25 for capacity change. Submit plan on if facility does not obtain fire clearance approval for bedridden, as discussed. Follow-up by 2/6/26 with "bedridden policy & procedures" for your plan of operation. POC due 1/28/26.
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: 01/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 01/27/2026 04:22 PM - It Cannot Be Edited


Created By: Dina Alviso On 01/27/2026 at 03:39 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: AILA CARE HOME
FACILITY NUMBER: 496804270

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA's review of records, the medication training documentation had no count of hours/time spent for the staff's training. Administrator was not able to provide staff, S2, S3, S4, and S5’s, medication "initial hours" of training, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2026
Plan of Correction
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Licensee/Administrator to ensure staff, S2, S3, S4, and S5, including any other staff that handles medications, have the staff obtain required HSC medication training, including the required number of hours as stated in HSC 1569.69.
POC due 2/13/26.
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: 01/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2026


LIC809 (FAS) - (06/04)
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