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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803639
Report Date: 09/16/2026
Date Signed: 09/16/2026 01:43:26 PM

Document Has Been Signed on 09/16/2026 01:43 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:PEOPLE'S CARE CHARMIANFACILITY NUMBER:
496803639
ADMINISTRATOR/
DIRECTOR:		GARCIA, GUADALUPEFACILITY TYPE:
740
ADDRESS:5087 CHARMIAN DRTELEPHONE:
(707) 537-9795
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 4CENSUS: 4DATE:
09/16/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Guadalupe Garcia, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:57 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a case management visit and was greeted by facility caregiver. Administrator (Admin) Guadalupe Garcia arrived later.

On 7/29/26 CCL received an Incident Report indicating a medication error for resident (R1). Report indicates that on 7/26/26 Admin was contacted by facility staff requesting verification before administering a PRN medication for R1 due to not having a bowel movement within 12 hours.

Admin reviewed the bowel movement tracker and verified the date and time of the last documented PRN dose. Per Incident Report, there was no bowel movement recorded for R1 that day. So, staff administered the PRN medication.

However, approximately one (1) hour after the medication was administered, staff (S1) called facility to advise that they remembered that R1 did actually have a bowel movement, but they did not record it on the bowel movement tracker. Admin immediately contacted the on-call nurse to advise of the medication administration in error. On-call nurse advised that no adverse reactions would likely be caused by the PRN medication being administered.

Later in the day on 7/26/26 R1 was seen at the Emergency Room due to blood being observed in their private buttock area. Admin advised hospital staff of PRN medication administration error. Per Incident report, Emergency Room physician confirmed that the PRN medication administration error had not caused any harm or adverse reactions. R1 was subsequently evaluated, treated, and discharged back to the facility. Staff monitored R1 for any changes. R1 had a follow-up appointment the subsequent week.

Continued on 809C...

Victoria Bertozzi
Christi Coppo
DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2026
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: PEOPLE'S CARE CHARMIAN
FACILITY NUMBER: 496803639
VISIT DATE: 09/16/2026
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Continued from 809...

LPA reviewed discharge papers and telephone follow up doctor's notes for R1. Discharge papers indicate follow up appointment. LPA reviewed follow-up appointment summary from 7/31/26. No adverse reactions observed.

Per Admin, S1 has been terminated due to the pattern and consistency of medication related errors and failure to follow established procedures. All staff received additional training on proper documentation and medication administration. Additionally, Admin advised LPA that additional coaching and corrective action will be provided as needed to reinforce expectations for timely documentation and communication practices.

Additionally, LPA discussed two (2) recent Incident Reports submitted in August for R1 falling. LPA discussed with Admin reason for increased falls. LPA reviewed doctor's office visit notes which indicates R1's diagnosis as drug induced Parkinson's who presents with worsening tremor and functional decline.

A civil penalty in the amount of $250 is being assessed today for repeat violations within a 12 month period (see LICF21)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.



Exit interview conducted with Administrator and a copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2026 01:43 PM - It Cannot Be Edited


Created By: Christi Coppo On 09/16/2026 at 10:27 AM
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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PEOPLE'S CARE CHARMIAN
FACILITY NUMBER: 496803639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2026
Section Cited
CCR
87465(a)(4)

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Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed.

This requirement not met by licensee as evidenced by:
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Facility to submit copies of termination documentation of S1 by plan of correction due date. Additonally, facility conducted medication training following the medication error.
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Based on facility's submitted incident report indicating medication error for R1 which poses an immediate health, safety or personal rights risk to persons in care.
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Training records to be submitted to CCL by no later than plan of correction of due date.

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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2026


LIC809 (FAS) - (06/04)
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