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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210111734
Report Date: 10/14/2024
Date Signed: 10/14/2024 04:07:01 PM

Document Has Been Signed on 10/14/2024 04:07 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:WILD FLOWERS RCFEFACILITY NUMBER:
210111734
ADMINISTRATOR/
DIRECTOR:		ALLEN, C. ELIZABETHFACILITY TYPE:
740
ADDRESS:256 SUNSET PARKWAYTELEPHONE:
(415) 264-7399
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 3DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Administrator, Crystal Leser
Licensee, Elizabeth Allen		TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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10/14/2024, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. LPA met with Administrator, Crystal Leser and Licensee, Elizabeth Allen. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 3 residents in care. Facility approved/cleared for 6 non-ambulatory, 1 bedridden, and hospice waiver for 2.

At approximately 2:35 pm, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. 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.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 108.2 and 115.3 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected Sept, 2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Knives are located in the kitchen which were found to be locked and secured. Cabinets containing cleaning supplies were located in garage and found to be locked. Facility has a pool located in the backyard being gated and locked. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

At approximately 2:50 pm, LPA conducted review of 3 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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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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: WILD FLOWERS RCFE
FACILITY NUMBER: 210111734
VISIT DATE: 10/14/2024
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At approximately 3:10 pm, LPA conducted a review of 3 resident records. All records had the required documentation.

No deficiencies cited during today's inspection. 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
LIC400- Affidavit Regarding Client/Resident Cash Resources
Liability Insurance

Exit interview conducted with Administrator and a copy of this report was provided.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC809 (FAS) - (06/04)
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