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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804303
Report Date: 03/17/2025
Date Signed: 03/17/2025 03:50:47 PM

Document Has Been Signed on 03/17/2025 03:50 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:VILLA SEVILLEFACILITY NUMBER:
496804303
ADMINISTRATOR/
DIRECTOR:		MARIMBI, MARTHAFACILITY TYPE:
740
ADDRESS:2085 SEVILLE STREETTELEPHONE:
(707) 481-2509
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 0DATE:
03/17/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Alvin & Catherine Hamilton, Applicant's/Licensees TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Hansen arrived announced to conduct a pre-licensing inspection and was greeted by applicants Alvin and Catherine Hamilton. Facility does not currently have residents in care. Once obtained, applicant will submit proof of required liability insurance.

Facility is a two-story residence consisting of 8 bedrooms, 2 of which are staff on the 2nd story along with 4 additional resident bedrooms on the second story and two resident bathrooms. On the first floor there are 2 non-ambulatory resident bedrooms, 1 full ADA bathroom, dining room, kitchen, living room, and family room. The facility received a fire clearance approved on 1/6/2025 by Santa Rosa Department Fire Prevention for two (2) non-ambulatory residents in rooms 1 and 2 on the first floor and four (4) ambulatory residents in rooms 3,4,5, and 6, on the second floor. Facility has a dementia care program plan and a request for hospice waiver of two. Administrator certificate for Martha Marimbi #7018478740 expires on 3/21/2025.

At approximately 9:00am LPA/Applicant toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed emergency supply of non-perishable food and water. All resident rooms #1-6 are furnished per regulation with a bed, lamp, bedside table, and dresser. The second story houses laundry, and across is bathroom with locked cabinet under sink for cleaning and laundry supplies. Cleaning supplies will also be stored in a secured closet in hallway next to living room which will have a keypad lock as it will also store medications & files. Auditory alarms on all doors observed to be functional except kitchen exit door. There is a wraparound deck and on side of the driveway has an electric lift and easily accessible to non-am clients and a ramp in the back of the house. Water temperatures read at: 122.7, 126.1 and 127.5 degrees F which needs to be adjusted to 105-120 degrees F as stated per regulation.
Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
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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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: VILLA SEVILLE
FACILITY NUMBER: 496804303
VISIT DATE: 03/17/2025
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Continued from LIC809...

Items required to be repaired/addressed before licensure:

* Beds to be equipped with mattress pads.
* Auditory alarm on kitchen exit door.
* Downstairs staff bathroom, either lock or bar for residents if use.
* All bathrooms skid mats available need to be placed in shower.
* Deck area has debris that needs to be removed & around outside of deck to fence.
* 2 evacuation chairs to be placed at top of each staircase.
* Water heater needs to be adjusted to deliver required temperature of 105 to 120 F degrees as stated per regulation.
* Window screen to be replaced on upstairs window at top of stairs
* Locks to be placed on upstairs bathroom cabinet under sink containing cleaning supplies.
* Keypad lock to be placed on living room hallway closet that will contain medications & files.
* Kitchen trash can with tight fitting cover
* 2 Night lights in hallway
* Front gate repair to be finished

Smoke and carbon monoxide detectors (combination) are hardwired throughout house and functioning. Four [4] fire extinguishers present and purchased 2025. First aid kit present with all required items. LPA observed all required postings including the CCL Complaint Poster, Long Term Care Ombudsman Poster, Resident's Rights, and the rights to Resident and Family Councils. Activity calendar and sample of menu submitted to the Centralized Application Unit (CAB).

Applicant agreed to notify Community Care Licensing once all repairs and personal accommodations are completed. LPA will conduct a subsequent visit to confirm required repairs had been completed. LPA will notify CAB analyst. LPA/Applicant reviewed and completed Component III orientation.
Exit interview conducted with Applicant and a copy of this report given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC809 (FAS) - (06/04)
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