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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803924
Report Date: 10/13/2026
Date Signed: 10/13/2026 12:06:20 PM

Document Has Been Signed on 10/13/2026 12:06 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:SONOMA GROVEFACILITY NUMBER:
496803924
ADMINISTRATOR/
DIRECTOR:		ALEXANDER VARSHAVSKYFACILITY TYPE:
740
ADDRESS:765 DONALD STREETTELEPHONE:
(707) 996-2161
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY: 32CENSUS: 25DATE:
10/13/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:Marlene Guerrero (lead caregiver)TIME VISIT/
INSPECTION COMPLETED:
12:21 PM
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Licensing Program Analyst (LPA) Marisol Cuadra arrived unannounced to conduct a Case Management - Incident visit and was greeted by Aaron Fryer, back up administrator who was fingerprint cleared, but not associated to the facility. LPA informed Licensee Julia Latifi that back up administrator is not associated to facility and should never be working and providing care to residents prior to a criminal record clearance or exemption. Licensee was not able to come to the facility, but was available by phone and associated them during LPA's visit. LPA was provided with proof of association through Guardian.

The purpose of the visit was to follow up on SOC341 that was submitted to Community Care Licensing (CCL) on 10/12/26. On 10/12/26, CCL received an SOC341 from an outside party reporting suspected deprivation of care involving resident (R1) who is experiencing a cognitive decline with signs of disorientation and dementia. Per report, R1 was admitted to this facility on 10/1/26, but R1 was no longer attending to receive dialysis services because they were placed on hospice raising concerns about R1 been aware of this changes. During today's visit, LPA confirmed that R1 was placed on hospice as of 10/1/26 and dialysis was discontinued. Based on records review, the facility has a hospice waiver from the department in accordance with the number of residents allowed, R1 is in a private room.
Continue on LIC809C...
Bethany Moellers
Marisol Cuadra
DATE: 10/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2026
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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Document Has Been Signed on 10/13/2026 12:06 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 10/13/2026 at 11:19 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: SONOMA GROVE
FACILITY NUMBER: 496803924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2026
Section Cited
CCR
87458(a)

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87458(a) Medical Assessment. Prior to accepting a person as a resident the licensee must obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. This requirement is not met as evidenced by:
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Licensee agrees to obtain an updated medical assessment and submit to CCL by POC due date to clear the citation.
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Based on record review and interview with licensee the facility failed to ensure R1's medical assessment prior to admission, which poses a potential risk to the health & safety of residents in care.
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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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2026


LIC809 (FAS) - (06/04)
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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: SONOMA GROVE
FACILITY NUMBER: 496803924
VISIT DATE: 10/13/2026
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Continued from LIC809...

R1's file includes advance directive and/or resuscitative measures form, hospice care agreement indicating medications need to be stored secured and allows authorized staff or hospice nurse to assist them with medications, equipment supplied, personal care services, frequency of two times per week, identification of training needs for facility staff includes incontinence care, nutrition, hydration, infection control measures, transfers, turning and positioning, which is in compliance with facility admission agreement signed by R1's responsible party on 10/1/26. Staff training records on such topics was conducted on 10/1/26 by hospice agency representative. The facility maintains records of R1's medications which are centrally stored in accordance with regulations. The hospice care plan includes hospice agency contact information. Notification sent to Fire Marshall and licensing agency as of 10/1/2026 was observed. However, the facility does not have a current physician report (LIC602) for R1 with a diagnosis of terminally ill.

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

Exit interview was conducted with staff 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: 10/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2026
LIC809 (FAS) - (06/04)
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