486802066-6-11-2026-21-AS-CFES-DUXSUV-20260611141145

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486802066
Report Date: 06/11/2026
Date Signed: 06/11/2026 02:12:32 PM

Document Has Been Signed on 06/11/2026 02:12 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:	CLARIN'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	486802066
ADMINISTRATOR/ DIRECTOR:	CLARIN, JULIANA		FACILITY TYPE:	740
ADDRESS:	3024 CLEAR COAST COURT		TELEPHONE:	(707) 557-6837
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY: 6		CENSUS: 3	DATE:	06/11/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Licensee, Juliana Clarin (Melegrito)		TIME VISIT/ INSPECTION COMPLETED:	02:25 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 8:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1 Year Required Visit and met with Licensee, Juliana Clarin (Melegrito). Facility is a Residential Care Facility for the Elderly (RCFE) and serves residents with Dementia and has a plan of operation for dementia care and programming on file. Facility is a two story building and has an approved fire clearance for 6 non-ambulatory residents and an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were currently 3 residents in care and 1 staff member on-site. LPA was also informed that there were 2 residents on Hospice. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Licensee. LPA observed the following: Facility is a two story building, where the first floor is designated for residents and the second floor is designated for caregivers/facility staff members only. Facility has a gate at the stairwell to ensure the second floor is inaccessible to residents in care. First floor consists of three (3) resident rooms, two (2) bathrooms, and common spaces. Second floor consists of three (3) staff/caregiver rooms and one (1) bathroom. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 3 sinks were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility fire extinguisher was last inspected April 2026. Smoke and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted May 2026. Facility's emergency disaster plan was last reviewed 2025. Facility was observed to have an adequate supply of emergency water accessible in the event they needed to shelter in place for 72 hours. Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026

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: CLARIN'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 486802066
	VISIT DATE: 06/11/2026

NARRATIVE

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Continued from LIC809

During walkthrough, LPA observed multiple instances of expired food in facility fridge and garage including canned beans,
milk, peppers, sausage, and salad kits. LPA and Licensee discussed checking the food storage areas every few days to ensure that food stays safe for consumption. LPA observed an empty container of Comet powder cleaner located under the sink of a resident bathroom. Licensee immediately disposed of expired food and empty Comet container. LPA observed a bottle of Periogard oral rinse located in a resident's bathroom medication cabinet. Licensee immediately made oral rinse solution inaccessible and placed it in facility's locked medication closet.

LPA reviewed staff files, resident files and resident medication. All files were all found to be well organized, thorough, and contained required documentation. Staff files had current first aid/CPR certification. Resident files had updated assessments and appraisals. Medication was centrally stored and secure. Administrator's Certificate for Juliana Melegrito (7006827740) was current with an expiration of 01/27/2027.

LPA discussed with Licensee on ensuring that resident appraisals/needs and services plans address behavioral expressions if they have been identified in resident medical assessments.

LPA also reviewed outstanding deficiencies that were cited in 2023, 2024, and 2025.

During visit conducted on 07/21/2023, the following regulations under California Code of Regulations (CCR) and Health and Safety Code (HSC) were cited:

CCR Maintenance and Operation 87303(i)(1) - Licensee was to submit a written plan and proof of facility signal system working
HSC Other Provisions 1569.618(c)(3) - Licensee was to submit plan on how they would ensure facility staff members have current first aid/CPR certification and submit proof of certification.
HSC Other Provisions 1569.625(b)(2) - Licensee was to submit proof of annual training for identified staff member

During visit conducted on 07/19/2024, the following regulation under CCR was cited:

CCR Maintenance and Operation 87303(e)(3) - Licensee was to submit a written statement and a weekly water temperature log

During visit conducted on 05/27/2025, the following regulation under CCR was cited:

Criminal Record Clearance 87355(e)(3) - Licensee was to associate identified staff members to facility roster or submit appropriate association paperwork to the Regional Office

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CLARIN'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 486802066
	VISIT DATE: 06/11/2026

NARRATIVE

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Continued from LIC809C

Review of facility documents and fax confirmations showed that Licensee submitted proof of corrections on the following dates:

2023 visit:

CCR Maintenance and Operation 87303(i)(1) - written statement and proof of signal system sent on 08/03/2023.
HSC Other Provisions 1569.618(c)(3) - written statement and proof of first aid/CPR for identified staff members sent on 08/07/2023
HSC Other Provisions 1569.625(b)(2) - proof of annual training for identified staff member sent on 08/14/2023.

2024 visit:

CCR Maintenance and Operation 87303(e)(3) - proof of weekly water temperature log sent on 08/20/2024.

2025 visit:

Criminal Record Clearance 87355(e)(3) - proof of LIC9182/Background Clearance Transfer Request for identified staff members sent on 05/28/2025.

All outstanding deficiencies from 2023, 2024, and 2025 have been cleared and plan of corrections letters provided during today's visit.

LPA discussed the following with Administrator:

Reporting Requirements
PIN regarding 911 protocols
PIN regarding dementia regulations

LPA requested the following documents to update facility file:

Designation of Facility Responsibility (LIC 308)
Emergency Disaster Plan (LIC 610E)
Liability Insurance
Active and Current Administrator Certificate

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CLARIN'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 486802066
	VISIT DATE: 06/11/2026

NARRATIVE

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Continued from LIC809C

Documents to be submitted to Community Care Licensing (CCL) by due date of 07/11/2026.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), LIC9102 (Technical Advisories/Violations), Plan of Corrections, and Appeal Rights discussed and provided to Licensee. Signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/11/2026 02:12 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 06/11/2026 at 01:40 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CLARIN'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 486802066
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(a)

General Food Service Requirements

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made, Licensee did not comply with the section cited above. Multiple instances of expired foods were observed in facility's refrigerator and garage storage including expired canned beans, milk, peppers, sausage, and salad kits. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/22/2026
	Plan of Correction
1 2 3 4	Licensee to submit a written statement on how they will ensure that facility food is stored in a safe and healthful manner. Statement to be submitted to Community Care Licensing (CCL) by POC due date of 06/22/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

	Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026

LIC809 (FAS) - (06/04)

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