496804399-6-4-2026-21-AS-MCUA-DUQQ3X-20260604114927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804399
Report Date: 06/04/2026
Date Signed: 06/04/2026 11:50:06 AM

Document Has Been Signed on 06/04/2026 11:50 AM - 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:	HERSHEY SENIOR CARE LLC		FACILITY NUMBER:	496804399
ADMINISTRATOR/ DIRECTOR:	MUNGAI, PHOEBE		FACILITY TYPE:	740
ADDRESS:	2546 HERSHEY CT		TELEPHONE:	(707) 843-7419
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 6		CENSUS: 2	DATE:	06/04/2026
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Phoebe Mungai (Licensee)		TIME VISIT/ INSPECTION COMPLETED:	12:05 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	Licensing Program Analyst (LPA) Cuadra arrive unannounced for the purpose of conducting Post-Licensing inspection visit and met with Administrator/Licensee Pjoebe Mungai. The facility has a dementia care plan and hospice waiver for two residents. There is one resident receiving hospice services. Required postings observed. The facility received a fire clearance approval on 12/18/2025 by the Santa Rosa Fire Department for total capacity of six (6) residents which five (5) may be non-ambulatory residents in single occupancy rooms #1, #3, #4, #5 and #6; Room #2 is single occupancy and cleared as a bedridden room. LPA/Administrator toured the facility inside and outside. Facility is a one story building, with a total of six bedrooms, two full bathrooms, small bathroom, office/launch room, laundry area located in the garage, kitchen, dining room, living room as common areas an outside sitting and garden area available for residents' use. The facility was inspected and found to be clean and in good repair at the time of the inspection with all exits free from obstruction. Fire Extinguishers were charged and serviced as of December 2025. All auditory alarms, Smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of the inspection. Hot water temperature measured at 105.2 degrees in resident's bathrooms which is not within regulation. Resident records, personnel records, medication and toxins were locked and inaccessible to resident's in care. Facility has first aid kit which was found to be appropriate during the Post-Licensing inspection. There is outdoor space for activities. Continued on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HERSHEY SENIOR CARE LLC	FACILITY NUMBER: 496804399
	VISIT DATE: 06/04/2026

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Continued from LIC809...

All resident’s bedrooms have lighting & appropriate furnishings, and resident’s beds were outfitted with mattress pads as required by Title 22 Regulations. The Licensee stated that they have not conducted a fire drill as of today yet because there are no staff (technical advisory). LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

File review initiated at 9:30am. One staff file and two resident's file was reviewed. Resident has medical assessment and care plan on file. Staff have required CPR/1st aid certificate and initial training 40 hours complete. During Pre-licensing, Licensee agreed that they need to include the use of surveillance cameras in common areas outside to their admission agreement to make residents and their responsible parties aware of their use without audio. However, after conducting file review LPA/Licensee observed that it wasn't included into current lease agreements on file. Licensee agreed to update lease agreements (technical violation issued). Administrator certificate for administrator Phoebe Mungai #7030487740 expires on 2/9/2027. Contact information reviewed. Medication and medication records reviewed.

The Licensee agreed to submit updated copies of the following documents by 06/18/2026: LIC500- Personnel Report, LIC308- Designation of Responsibility and liability insurance.

No deficiencies were cited during this Post-Licensing inspection. Exit interview was conducted with Licensee, 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: 06/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026

LIC809 (FAS) - (06/04)

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