286804382-9-25-2026-21-AS-JFLO-DY9TMY-20260925145154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804382
Report Date: 09/25/2026
Date Signed: 09/25/2026 02:52:03 PM

Document Has Been Signed on 09/25/2026 02:52 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:	AGING IN THE BAY 3		FACILITY NUMBER:	286804382
ADMINISTRATOR/ DIRECTOR:	MENDAROS, CHARMAINE		FACILITY TYPE:	740
ADDRESS:	1088 Donaldson WAY		TELEPHONE:	(510) 388-7352
CITY:	American Canyon	STATE: CA	ZIP CODE:	94503
CAPACITY: 6		CENSUS: 4	DATE:	09/25/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Charmaine Mendaros, Administrator/Prospective Licensee		TIME VISIT/ INSPECTION COMPLETED:	03:00 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	At approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a pre-licensing inspection and was greeted by staff. Administrator/Prospective Licensee was contacted via telephone and arrived at approximately 11:00 AM. This pre-licensing inspection is being conducted for a change of ownership of a Residential Care Facility for the Elderly (RCFE) with 4 residents currently in care. Fire Clearance has been approved for 6 non-ambulatory residents, 4 of whom may be bedridden. Facility has a dementia care plan and will apply for a hospice waiver for 4. At approximately 11:15 AM, LPA initiated a tour of the facility with Administrator/Prospective Licensee and observed the following: Facility is a one story building, was a comfortable temperature, and passageways were free from obstructions. LPA observed the required signs posted in the front entry area. Water temperature in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed resident showers with the required non-slip mats and grab bars in place. LPA observed a supply of clean linens, hygiene products, and paper products available for residents. Residents' bedrooms were inspected and observed to have the appropriate furnishings as outlined in regulations. Rooms, closets, and cabinets in communal areas of the facility containing cleaning supplies and other items that could pose a risk were observed locked. Facility has at least two days of perishable foods and one week of non-perishable foods and an emergency water supply. Residents were observed resting in their rooms or out in main communal area of the facility watching TV or visiting with staff. The facility telephone was tested and operational during inspection. Facility has internet service and an internet access device designated for resident use. Continued on LIC809-C...

Bethany Moellers
Julie Florio
	DATE: 09/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026

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: AGING IN THE BAY 3	FACILITY NUMBER: 286804382
	VISIT DATE: 09/25/2026

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continued from LIC809...

LPA observed a locked medication cabinet where medications are centrally stored and managed. LPA observed the facility's infection control plan, first aid kits, PPE, and other emergency supplies. Facility has a fully charged fire extinguisher which was last serviced 11/2025. Facility conducts quarterly emergency disaster drills with the most recent drill conducted 07/2026.

LPA conducted review of 3 staff and 4 resident files which were observed with the required documentation. Staff have proof of training and current first aid and CPR certifications.

Residents and their families mostly coordinate medical and dental visits and transportation to and from any such appointments. Facility staff are available to assist with coordination and offer third party transportation services when needed. The staff and administrator will remain the same under this new license. Administrator/Prospective Licensee has been informed of association and staff transfer process and agrees to ensure all staff are cleared and associated in Guardian. Administrator agrees to submit proof of liability insurance upon licensure.

Component III orientation completed with Administrator/Prospective Licensee. This pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager.

Exit interview conducted with Administrator/Prospective Licensee, whose signature on this document confirms receipt.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026

LIC809 (FAS) - (06/04)

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