496801754-3-20-2026-21-AS-CCOO-DSCUZH-20260320160134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801754
Report Date: 03/20/2026
Date Signed: 03/20/2026 04:01:55 PM

Document Has Been Signed on 03/20/2026 04:01 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:	WHITE ROSE MANOR		FACILITY NUMBER:	496801754
ADMINISTRATOR/ DIRECTOR:	REMOLLO-SANTOS, GEORGIANA		FACILITY TYPE:	740
ADDRESS:	313 SHEILA COURT		TELEPHONE:	(707) 776-0858
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY: 6		CENSUS: 5	DATE:	03/20/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:03 PM
MET WITH:	Glenda Castle, Designee		TIME VISIT/ INSPECTION COMPLETED:	04:15 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) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by designee. Facility currently has five (5) residents in care one (1)vof which are currently on hospice. Upon arrival, LPA observed caregiver (S1) present and working in facility but not listed on Guardian roster printed 3/19/26. During LPA inspection of physical plant S1 left the facility. Designee provided LPA with S1's personal information including birthday, driver's license, and last name, but this person turned out not to be the person that was actually presen. Person actually present was staff (S2). S2 name and birthday given to LPA. Per designee, S2 does not have fingerprint clearance. LPA advised S2 cannot return to facility until S2 has fingerprint clearance (deficiency cited, see 809D). Licensee is aware that S2 did not have fingerprint clearance as she is the one responsible for hiring staff and associating staff to facility. At approximately 2:40pm LPA 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. Box containing 150 eggs left outside of refrigeration inside garage, temperature today was 96 degrees F outside (deficiency cited, see 809D) LPA observed refrigerator to not be cool, no temperature reading available but refrigerator was leaking. Garage has two [2] refrigerators and one freezer. Per designee, the other refrigerator has also been leaking and licensee is aware. Light is broken on refrigerator in kitchen. Tile around kitchen sink is in disrepair and showing areas of black and gray substance (deficiency cited, see 809D). Cleaning products and laundry soaps are inaccessible to residents in care. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required grab bars but private bath in room #1 did not have mat. Water temperature in sinks measured at 109.2 degrees F in Continued on 809C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026

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: WHITE ROSE MANOR	FACILITY NUMBER: 496801754
	VISIT DATE: 03/20/2026

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Continued from 809...

the kitchen and 109.3 degrees F in the bathroom used by residents, both of which are within the allowable range of 105 to 120 degrees F. Facility has another bathroom used by staff only.

Fire extinguishers were last inspected 1/14/25, but showing as fully charged. Smoke/Carbon Monoxide detectors tested and operational. During inspection of physical plant LPA observed medication cabinet to be open and unlocked (deficiency cited, see 809D). Additionally, LPA observed medications and supplements in staff room, however, room was locked. LPA advised it could be a good practice to keep all prescription medications if not locked, then secured in a drawer or something in the event that the staff room is accidentally left unlocked. Fireplace in dining area needs a screen.

LPA spoke to resident (R1) who informed LPA that staff make all the residents go to their rooms between the hours of 1pm and 3pm. R1 informed LPA that they wanted to go outside but was told they had to stay in their room. LPA immediately informed staff that residents have personal rights, one of which is to have to make choices concerning their daily life in the facility (deficiency cited, see 809D). LPA observed residents lying in bed staring at the wall or ceiling. LPA advised designee residents need to have activities to participate in and have cognitive stimulation that meets their needs (deficiency cited, see 809D).

LPA will return at a later date to conduct file review, complete inspection, and issue citations on 809Ds for those items noted today as deficiency cited.

Exit interview conducted with designee and a copy of this report given.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026

LIC809 (FAS) - (06/04)

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