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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804279
Report Date: 05/22/2025
Date Signed: 05/22/2025 03:31:15 PM

Document Has Been Signed on 05/22/2025 03:31 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:ELSA CARE HOMEFACILITY NUMBER:
496804279
ADMINISTRATOR/
DIRECTOR:		WAINAINA, KENNEDYFACILITY TYPE:
740
ADDRESS:10 CREEKVIEW COURTTELEPHONE:
(707) 539-5625
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 4DATE:
05/22/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Kennedy Wainaina, AdminTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a pre-licensing inspection and was greeted by caregiver. LPA contacted licensee Victoria Wainaina to advise LPA here to complete Pre-licensing inspection. Facility Administrator, Kennedy Wainaina arrived later. Facility currently has four [4] residents in care. LPA reviewed staff roster. LPA and Admin transferred all current staff from facility Elsa's Home 496803960 to Elsa Care Home 496804279.

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. Food was found to be stored in a safe manner with open items covered. LPA observed within regulation emergency supply of non-perishable food. Garage stores two [2] overflow food refrigerators. Garage has locked metal cabinet that stores toxins and cleaning products. One locked drawer in kitchen is dedicated for sharp knives. Cleaning products under kitchen sink locked.

Facility is a one story residence with seven [7] bedrooms, one of which is a dedicated staff room, rooms one [1] and two [2] have a jack and jill style shared bath and room six [6] has a private half bath. Facility has two full bathrooms, dining and living room common areas, and a front sitting area used primarily for facility office administration. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Facility has central air and a back up generator. Present in the dining room is a ring camera. LPA asked Admin if there was a resident notification signed and on file, disclosing the video camera. Admin will provide disclosure notification to LPA before license is issued.

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NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2025
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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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: ELSA CARE HOME
FACILITY NUMBER: 496804279
VISIT DATE: 05/22/2025
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Water temperatures read at: 105.2 F in kitchen, 108.3 F in main bath, and 107.5 in full bath next to rooms five and six, all of which are within regulation of 105 & 120 degrees F.

Smoke and carbon monoxide detectors present and functioning, last serviced by vendor January 2025. Facility has fire extinguishers present and charged, last serviced 2/10/25. Emergency lighting lanterns present in living room. LPA observed all required postings and posters present.

Facility is currently and actively replacing left hand side of perimeter fence. LPA spoke to construction team and inquired as to portion of fence in the very front portion of the right hand side of the facility. Construction person indicated that currently, it is not scheduled to be replaced. LPA discussed with Admin that this portion of the fence will also need to be replaced in addition to the portion of the fence currently being replaced. Construction person informed LPA that estimated completion date of the fence should be by this Saturday, May 24, 2025. LPA showed Admin what appeared to be dry rot on bottom portion of front deck and some loose boards. LPA advised Admin to keep an eye on the stability of the deck structure and to replace once stability is no longer secure. Admin agreed and will have deck replaced/repaired if/when structure becomes unstable.

LPA reviewed facility sketch. Sketch found to be accurate and depicts location of water, gas, and electrical shut offs as well as location of smoke and carbon monoxide detectors.


LPA reviewed staff and resident files. The following items to be corrected prior to LPA submission of facility's application for approval: Training for all staff to meet hours requirement per regulation HSC1569.625(b), all staff must complete an additional 4 hours of dementia training with the following exceptions: S3 needs to complete annual continuation of training in the amount of 20 hours per HSC1569.625(b)(2) and S4 must complete 15 hours of training, six of which must be on dementia care. Additionally, S1, S2, and S4 need current 1st Aid/CPR and S1 needs a Health Screen (TB clearance is present and on file).


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NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ELSA CARE HOME
FACILITY NUMBER: 496804279
VISIT DATE: 05/22/2025
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The following items to be corrected prior to LPA submission of facility's application for approval:
  • Repair two loose boards on right hand side of backyard fence
  • Screen to sliding glass door torn and cut in multiple places
  • Street-facing front right hand side portion of fence to be replaced
  • Signed resident notification of disclosure of camera in living room
  • All staff must complete an additional 4 hours of dementia training with the following exceptions: S3 needs to complete annual continuation of training in the amount of 20 hours per HSC1569.625(b)(2) and S4 must complete 15 hours of training, six of which must be on dementia care.
  • S1, S2, and S4 need current 1st Aid/CPR
  • S1 needs a Health Screen (TB clearance is present and on file).


Administrator to provide photos and/or videos of repaired/replaced items. Once acceptable photographic and/or video proof of corrections is received by CCL, LPA will submit facility's application for approval.

Comp III reviewed and exit interview conducted with Administrator and a copy of this report given.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC809 (FAS) - (06/04)
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