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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804217
Report Date: 06/05/2026
Date Signed: 06/05/2026 04:10:31 PM

Document Has Been Signed on 06/05/2026 04:10 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:WILLOWS NURSING HOMEFACILITY NUMBER:
496804217
ADMINISTRATOR/
DIRECTOR:		RELOTA, EDENFACILITY TYPE:
740
ADDRESS:5926 ANSON DRTELEPHONE:
(707) 843-4650
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 5DATE:
06/05/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Eden Relota, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Eden Relota arrived later. Eden Relota Administrator Certificate 7006928740 expires 11/25/26.

At approximately 1:00pm LPA and caregiver toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. Room #3 had broken chest of drawers. Caregiver immediately replaced with chest of drawers from vacant room. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperatures in sinks accessible to residents in care measured at 131.8 degrees F in the kitchen, 131.7 degrees F in the main hall bath and 134.4 in room #1 which is not within the allowable range of 105 to 120 degrees F (deficiency cited, see 809D). Additionally, water in room #3 does not have much pressure and does not get hot at all. LPA and caregiver let water run for approximately 5 minutes but water still did not get hot, LPA measured 88 degrees F.

Fire extinguishers were last inspected 1/30/25. They are showing as fully charged. LPA discussed with Admin servicing them each year. Admin will get them serviced within 3 business days. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted on 4/2/26. Facility has a backup generator for use during a power outage. LPA observed rodent droppings in closet located in the dining room. However, caregivers and Admin advised licensee gets a regular service by EcoLab every month to address on going problem. However, Admin could not produce

Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2026
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: WILLOWS NURSING HOME
FACILITY NUMBER: 496804217
VISIT DATE: 06/05/2026
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Continued from 809...

most current copy of EcoLab service report. Admin to forward to LPA by Monday, 6/8/26. LPA and caregiver observed small amount of dog feces in side yard. Residents are ambulatory and enjoy the outside area often. LPA discussed ensuring all dog feces is picked up timely. LPA, caregiver, and Admin all observed resident exit doors to have alarms but they all were not working. Caregiver replaced batteries and got them working. LPA discussed with Admin making sure all creams and sprays that have active ingredients and warning labels are inaccessible to residents in care.

At approximately 2:00pm LPA conducted a review of five [5] resident records. Residents (R1 and R2) are on hospice. However, R2 did not have a hospice care plan on file (deficiency cited, see 809D). At approximately 2:30pm LPA conducted review of four [4] staff records. No deficiencies cited.

At approximately 3:00pm LPA and Admin conducted a spot check of medication and medication records. R2 most current physician's orders were dated 3/25/26 and listed Albuterol HFA 90mcg but it was not listed on the Centrally Stored Medication Log (CSML)(deficiency cited, see 809D). R2 has Aripiprazole 10mg listed on doctor's orders but on CSML and bubble pack it lists 20mg. Admin to call immediately and get clarification and updated doctor's orders or medication with correct dosage (deficiency cited, see 809D). R2 clonazepam 1mg is listed on doctors orders and CSML but is has not been refilled (deficiency cited, see 809D). Per Admin, hospice nurse came today and they have refilled it and it will be delivered tonight.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

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 Administrator. 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: 06/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2026 04:10 PM - It Cannot Be Edited


Created By: Christi Coppo On 06/05/2026 at 03:41 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: WILLOWS NURSING HOME
FACILITY NUMBER: 496804217

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA and caregiver observation, the licensee did not comply with the section cited above in that
Physical Plant/Environmental Safety - Type A: 87303(e)(2) - water temperatures in sinks accessible to residents in care measured at 131.8 degrees F in the kitchen, 131.7 degrees F in the main hall bath and 134.4 in room #1 which is not within the allowable range of 105 to 120 degrees F (deficiency cited, see 809D). Additionally, water in room #3 does not have much pressure and does not get hot at all, LPA meaured 88 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2026
Plan of Correction
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Facility to submit plan to ensure water temperature remains within compliance by plan of correction due date. Seven (7) days water temperature log to be submitted to CCL no later than 6/29/26.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA and Admin record review, the licensee did not comply with the section cited above in that R2 clonazepam 1mg is listed on doctors orders and CSML but is has not been refilled, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2026
Plan of Correction
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2
3
4
Facility to submit plan to conduct medication training for all staff administering medication by plan of correction due dat. Training to be at least 1 hour and include proper medication management including refilling medication timely. Training to be condcuted no later than 6/29/26 and log to be submitted no later than 6/29/26.
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: 06/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2026 04:10 PM - It Cannot Be Edited


Created By: Christi Coppo On 06/05/2026 at 03:41 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: WILLOWS NURSING HOME
FACILITY NUMBER: 496804217

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(1)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that Albuterol HFA 90mcg on doctor's orders but it was not listed on the Centrally Stored Medication Log (CSML), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2026
Plan of Correction
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2
3
4
Facility to submit plan to conduct medication training for all staff administering medication by plan of correction due date. Training to be at least 1 hour and include proper medication management including refilling medication timely. Training to be condcuted no later than 6/29/26 and log to be submitted no later than 6/29/26.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA and Admin record review, the licensee did not comply with the section cited above in that R2 has Aripiprazole 10mg listed on doctor's orders but on CSML and bubble pack it lists 20mg. Admin to call immediately and get clarification and updated doctor's orders or medication with correct dosage, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2026
Plan of Correction
1
2
3
4
Facility to submit plan to conduct medication training for all staff administering medication by plan of correction due date. Training to be at least 1 hour and include proper medication management including refilling medication timely. Training to be condcuted no later than 6/29/26 and log to be submitted no later than 6/29/26.
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: 06/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2026 04:10 PM - It Cannot Be Edited


Created By: Christi Coppo On 06/05/2026 at 03:41 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: WILLOWS NURSING HOME
FACILITY NUMBER: 496804217

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(d)
Hospice Care for Terminally Ill Residents
(d) The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client's care needs are being met at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin record review, the licensee did not comply with the section cited above in that R2 did not have hospice care plan on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2026
Plan of Correction
1
2
3
4
Facility to submit to CCL copy of R2's hospice care plan but plan of correction due date.
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:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2026


LIC809 (FAS) - (06/04)
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