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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920289
Report Date: 09/29/2026
Date Signed: 09/29/2026 01:30:09 PM

Document Has Been Signed on 09/29/2026 01:30 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ADDIS HOME CARE LLCFACILITY NUMBER:
345920289
ADMINISTRATOR/
DIRECTOR:		ORTIZ, MARKMURPHYFACILITY TYPE:
740
ADDRESS:4800 Ipswitch CTTELEPHONE:
(952) 564-5468
CITY:Fair OaksSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 3DATE:
09/29/2026
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Yenne Tezera, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with Licensee, Yenne Tezera, to conduct a plan of correction (POC) visit to follow-up on a citation issued during an inspection conducted on April 9, 2026.

During visit conducted on April 9, 2026, LPA issued a deficiency with the POC that the facility would refund resident (R1’s) authorized representative fees paid from February 10, 2026 to February 28, 2026 and would submit proof to the Department that refund was issued by POC due date of June 9, 2026. During today’s visit, LPA inquired Licensee whether they refunded R1’s authorized representative fees paid from February 10, 2026 to February 28, 2026. Licensee stated that they had yet to issue a refund to R1's authorized representative as of today's date.

Prior to visit conducted on April 9, 2026, Relevant party reported that R1 resided at the facility from February 1, 2026 to February 7, 2026. R1 passed away on February 7, 2026. Relevant party reported that R1’s authorized representatives did not receive a prorated refund for rent that was paid in advance for the month of February, 2026. Interview with Licensee indicated that R1 was admitted to the facility on January 31, 2026 and passed away on February 7, 2026. Licensee indicated that they had not issued a refund to R1’s authorized representatives as the facility did not issue refunds upon the death of a resident receiving hospice services per admission agreement signed by R1’s authorized representative.

** Report continued on 809-C **
Anthony Perez
Michael Hood
DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2026
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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ADDIS HOME CARE LLC
FACILITY NUMBER: 345920289
VISIT DATE: 09/29/2026
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LPA reviewed Admission Agreement signed by R1’s authorized representative, which states “REFUND POLICY: Refund policy for this facility is ‘Please note that payment are not refundable & a 30 days notice is required for any cancellations/changes.’”

Per Health and Safety Code §1569.652(c), “A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.” Per Title 22, Division 6, Chapter 8, Section 87507(h)(4), “The admission agreement shall not contain the following: Any provision that violates the rights of any residents including but not limited to those specified in Section 87468 and in Health and Safety Code section 1569 et seq.”

Relevant party reported that R1’s property was removed from their room to the garage on February 8, 2026 and R1's Power of Attorney removed R1's property from the care home on February 10, 2026. Licensee stated that R1's property was removed from the care home on February 9, 2026.

As a result of today's inspection, a deficiency is being cited pursuant to Health and Safety Code section 1569.652 regarding termination of admission agreement upon death of resident. A civil penalty in the amount of $250 is assessed for today's date due to repeat violation. Deficiency is listed on 809-D page.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2026 01:30 PM - It Cannot Be Edited


Created By: Michael Hood On 09/29/2026 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ADDIS HOME CARE LLC
FACILITY NUMBER: 345920289

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2026
Section Cited
HSC
1569.652(c)

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§1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement is not met as evidenced by:
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Facility will refund R1’s authorized representative fees paid from February 10, 2026 to February 28, 2026. Facility will contact R1's authorized representative to establish refund payments and when refund shall be completed by POC due date of October 5, 2026.
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Based on interviews conducted and records reviewed, the facility did not ensure to issue a refund for advance fees paid to R1’s authorized representative upon the removal of R1’s property after they passed away, which poses a potential health, safety, and/or personal rights risk to the residents in care.
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Facility will submit proof of correspondence to LPA by POC due date.

A civil penalty in the amount of $250 is assessed for today's date due to repeat violation.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Michael Hood
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2026


LIC809 (FAS) - (06/04)
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