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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804333
Report Date: 02/19/2026
Date Signed: 02/19/2026 01:59:05 PM

Document Has Been Signed on 02/19/2026 01:59 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:GOLDEN YEARS RETREAT INCFACILITY NUMBER:
496804333
ADMINISTRATOR/
DIRECTOR:		BELAINEH, DAWITFACILITY TYPE:
740
ADDRESS:4040 SHADOWHILL DRTELEPHONE:
(651) 221-9820
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 0DATE:
02/19/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Dawit Belaineh, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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At approximately 8:45 AM, Licensing Program Analyst (LPA) Robert Frank arrived for a scheduled visit to conduct a pre-licensing inspection and was greeted by Licensee/Applicant/Administrator, Dawit Belaineh. This pre-licensing inspection is being conducted for an initial licensing of a Residential Care Facility for the Elderly (RCFE). Fire Clearance has been approved for six (6) non-ambulatory residents. All bedrooms are approved for non-ambulatory use. Applicant did not ask for approval for bedridden residents by the local fire department.

At approximately 9:05 AM, LPA initiated a tour of the facility and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. Applicant had non-slip mats and grab bars in place. LPA observed a supply of clean linens, and paper products available for residents. Residents' bedrooms have all the appropriate furnishings as outlined in Title 22 regulations.

LPA observed dishes and cooking supplies for resident use with sharps and other hazardous items kept secured in locked cabinets. Applicant agrees to keep magnets and keys to these locked areas in facility safe secured and inaccessible to residents in care. Licensee agrees to maintain at least two days of perishable foods and one week of non-perishable foods and an emergency water supply. The required posters were not observed hanging in the facility. Licensee/applicant will purchase a long-term care ombudsman poster and the PUB 475 Facility Complaint poster which will be hung on a wall in a common area prior to resident occupancy. Applicant has posted a copy of their admissions agreement and emergency disaster plan in a common area of the facility.

Continued on 809-C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2026
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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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: GOLDEN YEARS RETREAT INC
FACILITY NUMBER: 496804333
VISIT DATE: 02/19/2026
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...Continued from 809

The facility currently has the Applicant associated to facility in Guardian and will hire an additional staff members once license is approved. Applicant has been informed of association and staff transfer process. Applicant will provide an ipad/computer for residents to use. Facility phone/land line was observed to be operational.

Facility has a designated locked cabinet for centrally stored medications. LPA observed a first aid kit and other emergency supplies. LPA recommended that Applicant add additional, age appropriate activities for elderly residents. Facility has multiple fire extinguishers, which are brand new and fully charged. Smoke and Carbon Monoxide detectors were tested and observed to be operational during inspection. LPA reviewed a facility sketch which was observed to accurately reflect the floor plan.

The backyard features a shaded patio area for resident use. Windows, screens, and blinds were all observed in good repair.

Prior to admitting residents, applicant will: remove bricks and tiles from back yard patio area; purchase night lights for hallways; purchase individual bins so that resident's medications are separated; add a door lock to the laundry area; add a door lock to the garage; remove half-rails from all beds; finish minor repair work in closet of bedroom #4 as marked on facility drawings.

LPA and Licensee/Applicant discussed the following items:

  • Hospice Waiver - Applicant to apply for a waiver if it's decided they want hospice care in the facility. Requirements for a Hospice Waiver and a Hospice Exception along with copies of 87632 Hospice Care Waiver & 87633 Hospice Care of Terminally Ill Residents regulation were provided to Licensee applicant.
  • Guardian background clearances and associations
  • Updated Dementia regulations. LPA discussed Licensee/Applicant providing a Dementia Care program in the future.
  • Technical Support Program (TSP). Licensee/Applicant expressed interest in the Department's TSP. LPA will submit a request for Technical Support on behalf of the Licensee/Applicant.
  • LPA provided Licensee/Applicant requirements for a Plan of Operation update needed to have video surveillance at the facility. Continued on 809-C2...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: GOLDEN YEARS RETREAT INC
FACILITY NUMBER: 496804333
VISIT DATE: 02/19/2026
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...Continued from 809-C

Component III orientation was conducted at facility with Dawit Belaineh.

Dawit Belaineh’s Administrator Certification 6072519740 is current with an expiration date of 10/28/2026.

Applicant will submit proof of liability insurance once facility has been licensed.

No Deficiencies given during visit. Pre-Licensing completed. Facility is ready to be Licensed as a Residential Facility for the Elderly (RCFE).

LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status.

Exit interview conducted. Copy of report discussed and provided to Applicant/Administrator Belaineh. Signature on form confirms receipt of document.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026
LIC809 (FAS) - (06/04)
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