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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801754
Report Date: 01/03/2024
Date Signed: 01/03/2024 03:40:13 PM

Document Has Been Signed on 01/03/2024 03:40 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:WHITE ROSE MANORFACILITY NUMBER:
496801754
ADMINISTRATOR:REMOLLO-SANTOS, GEORGIANAFACILITY TYPE:
740
ADDRESS:313 SHEILA COURTTELEPHONE:
(707) 776-0858
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 6DATE:
01/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Glenda Castle, DesigneeTIME COMPLETED:
03:50 PM
NARRATIVE
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual visit of the facility. LPA was welcomed by staff Glenda Castle. Georgiana R Santos Licensee/Administrator was contacted by facility staff on the telephone and wasn’t able to be present for this visit, LPA spoke with Licensee authorizing staff to sign documents. There is a total of six residents, 4 with diagnosis of dementia, 1 resident on hospice.

Facility tour/inspection began at 8:45AM:
LPA toured the facility with staff Evangeline; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices that were working properly during the visit. The one Fire Extinguisher was found to be last charged on 1/24/2022 at the time of the visit out of Title 22 regulations (see LIC809-D). Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured 107.7 degrees F and 108.6 degrees F in 2 out of 2 resident bathroom faucets which are within Title 22 acceptable regulation of 105 to 120 degrees F. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit; although cleaning supplies were stored under kitchen sink with food (see pic & LIC809-D) and were removed by staff. At approximately 9:00am LPA observed in kitchen with staff, broken lock on knife/sharps drawer which is a danger to residents in care (see pic & LIC809-D). Toxins are stored in the garage in a locked laundry cabinet; although on 1/3/2023 at 9:20am LPA observed cleaning supplies w bleach on floor in garage & laundry detergent in uncovered cup in resident bathroom at 9:30am in unlocked cabinet under sink (see pic & LIC809-D) both removed by staff. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings.

Continue on LIC809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
Document Has Been Signed on 01/03/2024 03:40 PM - It Cannot Be Edited


Created By: Shannan Hansen On 01/03/2024 at 02:12 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: WHITE ROSE MANOR
FACILITY NUMBER: 496801754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Designee's observation, the licensee did not comply with the section cited above as lock on knife drawar in kitchen was broken (see pics), and cleaning supplies (bleach) (see pic) were in garage, unlocke & detergent was in uncovered cup under sink in resident bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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LIcensee/designee to submit docuement 9098 to CCL they understand the regulation by POC due date 1/4/2024 and complete traininng with staff on regulations and submit title of training with staff signed, dated documentation by POC due date 1/19/2024 and picture of fixed lock. Designee immediately removed knives in drawer and placed in secure area and removed toxins from bathroom and garage and put in locked cabinit in garage.
Type A
Section Cited
CCR
87465(h)(2)
87465 (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care. LPA observed during tour of the facility medications in unlocked medication refrigerator. (see pictures)
POC Due Date: 01/04/2024
Plan of Correction
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Licensee/Designee to submit plan of how they will keep refrigerated medicaitons locked and secured from residnets, following regulation by POC due date 1/4/2024 and submit proof (pic) of secured medications by POC due date 1/5/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 01/03/2024 03:40 PM - It Cannot Be Edited


Created By: Shannan Hansen On 01/03/2024 at 02:12 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: WHITE ROSE MANOR
FACILITY NUMBER: 496801754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 1 out of 1 cabinet under kitchen sink contained cleaning products and onions, potatoes, and other food items etc.. which poses/posed a potential health, safety or personal rights risk to persons in care. Designee immedicately removed cleaning products to locked garage cabinet.
POC Due Date: 01/12/2024
Plan of Correction
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Designee/facility, agrees to conduct training on storage of food and not being kept with soaps, detergents, cleanign compounds,etc and send training with staffs signed, dated document to CCL with form LIC9098 by POC due date to clear deficiency.
Type B
Section Cited
CCR
87467(a)(3)
87467(a)(3)The licensee shall arrange a meeting with the resident and appropriate individuals to review and revise the written record as specified, when there is a significant change in the resident’s condition, or once every 12 months, whichever occurs first. This requirement is not met as evidence by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not review & update the written needs & care assessment in the last 12 months in 4 of 6 residents which poses a potential health, safety risk to residents in care. LPA review records for resident R1, R2, R3, & R4 and learned that needs &services plans all dated 2022..
POC Due Date: 01/19/2024
Plan of Correction
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Licensee to ensure that all residents Appraisals Needs and Service Plans are current, updated,& done as frequently as necessary for all residents to ensure that residents are receiving the appropriate level of care needed. Licensee must review Needs and Service Plan with staff, resident and their responsible parties. Licensee update plans and to obtain necessary signature of all parties. and submit a copy of R1-R4 updated care plan to CCL by POC date of 1/19/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024


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Page: 3 of 9
Document Has Been Signed on 01/03/2024 03:40 PM - It Cannot Be Edited


Created By: Shannan Hansen On 01/03/2024 at 02:12 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: WHITE ROSE MANOR
FACILITY NUMBER: 496801754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced by: Based on interview, the licensee did not comply w/section cited above in 1 of 1 facility drill which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Facility to ensure that facility will conduct quarterly disaster drills as required by Health & Safety Code. Licensee to submit to CCL proof of disaster drill conducted with the facility by POC date of 1/12/2024
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on residents' file review the licensee did not have annual medical assessment (602) for 1 out of 4 residents w/ dementia which poses a potential health, safety risk to residents in care. LPA reviewed files for residents on 1/3/24 and learned that R1's last Physicians assessment was on 10/25/2022.
POC Due Date: 01/19/2024
Plan of Correction
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Licensee to ensure reappraisals & medical assessments are done, review and update to ensure all resident's needs are met annually and/or if there is a change of condition, whichever comes first. Licensee to submit copy of an updated medical assessment for resident R1 by POC date of 1/19/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024


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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: WHITE ROSE MANOR
FACILITY NUMBER: 496801754
VISIT DATE: 01/03/2024
NARRATIVE
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File Review began at 10:30 AM:
A review of six resident & five staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files and learned that 4 out of 6 residents (R1,R2, R3, & R4) do not have an updated re-appraisals/needs & care plans and only 5 out of 6 residents have current physician’s reports. R1 has a diagnosis of dementia and does not have an updated physician’s assessment (LIC 602A) (see LIC 809-D’s).

LPA reviewed a sample of staff records and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements for 2023 are on file. LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed.

Medication Audit began at 1:45 AM:
Medications were centrally stored in locked cabinet in the facility office room area, however; during tour of the facility LPA observed unlocked kitchen drawer containing pre poured medications (see LIC 9102 for technical of pre poured medications). including unlocked mini refrigerator containing resident’s medications (see pic & LIC 809-D). Facility has a 30-day supply of medication for residents.

The Medications of 2 out of 2 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.



LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any of the information. Administrator Certificate for Administrator, Georgiano Santos 6019796740 expires 8/25/2024. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; and review facility emergency plan to ensure accuracy according to the needs of facility residents. Last Disaster Drill was conducted on 12/2/2022 (see LIC 809-D). Disaster drills are to be conducted quarterly and in different shifts.

Appeal of Rights Given.

Continue on LIC809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 01/03/2024 03:40 PM - It Cannot Be Edited


Created By: Shannan Hansen On 01/03/2024 at 03:11 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: WHITE ROSE MANOR
FACILITY NUMBER: 496801754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire dpt...This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Licensee/Administrator did not comply with the section cited above in 1 out of 1 fire extinguisher was not serviced since January 24, 2022 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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Licensee/Administrator will contact the Fire Department to have fire extinguisher serviced. Administrator agreed to submit self-certification form as a proof of Correction (POC) that fire extinguisher have been serviced and charged by a fire extinguisher service company or the Fire Department by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024


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: WHITE ROSE MANOR
FACILITY NUMBER: 496801754
VISIT DATE: 01/03/2024
NARRATIVE
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The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.


LPA Hansen is requesting facility to submit the following documents to CCL by 1/25/2024:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Resident’s
Copy of Current Administrators Certificate
Copy of Certificate of Liability Insurance
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC809 (FAS) - (06/04)
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