496804371-5-14-2026-21-AS-MCUA-DU3SUL-20260514141121

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804371
Report Date: 05/14/2026
Date Signed: 05/14/2026 02:11:42 PM

Document Has Been Signed on 05/14/2026 02:11 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:	FERNWOOD CARE FACILITY LLC		FACILITY NUMBER:	496804371
ADMINISTRATOR/ DIRECTOR:	CRUZ, ANTONIO G		FACILITY TYPE:	740
ADDRESS:	116 FERNWOOD COURT		TELEPHONE:	(707) 321-3711
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95401
CAPACITY: 6		CENSUS: 0	DATE:	05/14/2026
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:20 PM
MET WITH:	Antonio Cruz (Applicant)		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cuadra arrived announced to conduct a pre-licensing inspection and was greeted by Applicant, Antonio Cruz. Facility currently does not have residents in care. Once obtained, Applicant will submit proof of required liability insurance. The facility has submitted a dementia care plan. Applicant stated that they have applied for a hospice waiver for two residents, but LPA reviewed documentation provided by the Centralized Application Unit (CAB) and there was no hospice waiver on file. LPA will follow up with CAB Analyst to clarify if the facility does have a hospice waiver on file. Also, Applicant stated that they own the home, but LLC has a lease agreement as indicated in the application (LIC200). The facility received a fire clearance approval on 10/23/2025 by the Santa Rosa Fire Department for total capacity of six (6) residents which six (6) may be non-ambulatory residents in all rooms. Room #1 and #3 are approved for single occupancy rooms; Room #2 and Master bedroom #4 are cleared as shared rooms. Garage could not be used for resident's use. LPA/Applicant toured the building and grounds. The facility consists of a single story residence with a total of four bedrooms, three full bathrooms, laundry area located outside, kitchen, dining room, living room as common areas an outside sitting and garden area available for residents' use. All residents rooms are connecting to facility dinning room, living room and kitchen area through fire door. Room #2 allows access to the backyard and they have auditory alarms installed at the doors that were found operational during the visit. Confidential file storage of personnel and resident's records will be kept in the living room area locked and secured. The facility was found to be consistent with facility sketch, and at a comfortable temperature. However, Master bathroom needs one grab bar for toilet and Applicant will remove glass door and install curtains. Bathrooms located in the hallway will be designated for resident's use and it has grab bars and skid mats available. Applicant expressed that they would like to get a referral for Technical Support Program (TSP). Continues on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FERNWOOD CARE FACILITY LLC	FACILITY NUMBER: 496804371
	VISIT DATE: 05/14/2026

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Continued from LIC809...
All rooms and common area had sufficient lighting, including hallways. The smoke alarms are a combination of carbon monoxide are hardwired and were observed operational during inspection. Indoor and outdoor passageways are free of obstructions and is enough to permit residents with a diagnosis of dementia wander freely and safely. Window screens are clean and in good repair. Resident rooms are needed to be furnished per regulation as follow: Shared room #2 and Master Bedroom #4 needed a bed, bedside table, dresser and chair for second occupancy. Bedroom #3 needs a bed and bedroom #4 is ready for residents to move in. Trash cans with cover lids to prevent spread of communicable disease are needed in bedrooms.

First aid containing all items were observed. No surveillance cameras were observed. Garage houses incontinence care supplies and emergency supply of food and water. The facility doesn't have a generator yet. Cleaning supplies will be stored under locked kitchen sink. Sufficient supply of linens and hygiene products observed in linen closet located in the hallway. Kitchen cabinet has locks installed for knives and locked centralized medication to be inaccessible to residents in care. There are sufficient amount of dishes, utensils, cooking pots, etc. Activity calendar and supplies as well as sample of menu was observed. Water temperatures read at: 115.2 and 112.1 degrees F which is within 105-120 F degrees regulation. Fire extinguishers serviced on September 2025. Administrator certificate for administrator Antonio Gonzalez-Cruz #6071056740 expires on 6/4/2026. Facility contact information reviewed and updated landline phone number. 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.

Applicant agrees to submit the following items for LPA review:

Proof of grab bar in master bathroom for toilet.
Garbage cans with tight fitting covers for all bedrooms.
Shared room #2 and master bedroom #4 needed a bed, bedside table, dresser and chair for second occupancy.
Applicant will remove glass door and install curtain.
Bedroom #3 needs a regular bed.
Each room needs a call alert system to alert staff.

LPA will conduct component III and subsequent inspection after above items are submitted to confirm complete. After confirmed LPA will notify Application Unit pre-licensing inspection is complete and to proceed with licensure. Exit interview conducted with Applicant 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: 05/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

LIC809 (FAS) - (06/04)

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