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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801754
Report Date: 03/24/2026
Date Signed: 03/24/2026 03:56:29 PM

Document Has Been Signed on 03/24/2026 03:56 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 MANORFACILITY NUMBER:
496801754
ADMINISTRATOR/
DIRECTOR:		REMOLLO-SANTOS, GEORGIANAFACILITY TYPE:
740
ADDRESS:313 SHEILA COURTTELEPHONE:
(707) 776-0858
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 5DATE:
03/24/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:31 AM
MET WITH:Glenda Castle, DesigneeTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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On 3/24/26 LPA returned to this facility at approximately 9:30am to complete annual inspection. Previously, on 3/20/25 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 present. Person actually present was staff (S2). S2 name and birthday given to LPA. Per designee, S2 does not have fingerprint clearance but has been working for about 2 weeks at facility. LPA advised S2 cannot return to facility until S2 has fingerprint clearance (deficiency cited, see 809D and civil penalty assessed in the amount of $100 per day for 5 days for a total of $500, see LIC421BG). Licensee is aware that S2 did not have fingerprint clearance as she is the one responsible for hiring staff and associating staff to facility, not designee.

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 in garage to be storing food but was not cool, no thermostat so no temperature reading available but refrigerator was also leaking water out form the bottom. Garage has two [2] refrigerators and one freezer. Per designee, the other refrigerator has also been leaking and licensee is aware (deficiency cited, see 809D). Light is broken on

Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2026
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 14
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)
Page: 2 of 14
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: 03/24/2026
NARRATIVE
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Continued from 809...

refrigerator in kitchen. Tile around kitchen sink is in disrepair and showing areas of black and gray substance. Additionally, on 3/24/26 at approximately 2pm LPA spoke with visiting repair individual (I1) from HCB construction. I1 reported to LPA that sink has been leaking for quite some time. I1 reported to LPA that they observed under kitchen sink mold all over: plywood that has mold and has rotted, sides of the cabinet have mold, garbage disposal is covered with rust, and water lines are also covered with rust (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 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. LPA did not observe residents engaged in any activities for the duration of both LPA's visits (deficiency cited, see 809D). Additionally, R2's hospice care plan dated 3/6/26 on page 6 of 9 social worker indicates adding a TV to their room for additional diversion.

Continued on 809C(2)...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC809 (FAS) - (06/04)
Page: 3 of 14
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: 03/24/2026
NARRATIVE
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Continued form 809C...

Per designee, they were not aware of the social worker's suggestion. While LPA present, caregivers added a television to R2's room and adjusted their bed so as to have a good view.

On 3/24/26, LPA began resident file review at approximately 9:45am. LPA reviewed five [5] out of five [5] resident files. LPA observed full rails on bed for residents (R1 and R2). R2 is on hospice but R1 is not (deficiency cited, see 809D). Per designee they will remove full rails rather than request an exception.

LPA began staff file review at approximately 11:00am. S3, S4, and S5 do not have restricted conditions training on file and S6 does not have any training at all on file (deficiency cited, see 809D). S3 and S4 need 8 hours of in-service medication training completed each year (deficiency cited, see 809D). S5 and S6 need a total of 10 hours of initial medication training (deficiency cited, see 809D). S5 did have some medication testing documented but no hours of duration noted on documentation. Training completed by a vendor. Vendor not on the approved vendor list. LPA will forward to licensee approved vendor list. Additionally, S6 did not have a health screen or TB clearance on file (deficiency cited, see 809D).

At approximately 1:45pm LPA and designee did a spot check of medication and medication records. Medication is centrally stored in cabinet. Facility has mini-refrigerator for medication needing refrigeration. R1 had prescription for Doxycycline Monohydrate 100mg, that was not listed on the Centrally Stored Medication Log (CSML) and R3 did not have a CSML (deficiency cited, see 809D).

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

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with House Manager 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: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 03/24/2026 03:56 PM - It Cannot Be Edited


Created By: Christi Coppo On 03/24/2026 at 12:50 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.269(a)(8)
§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (8) To make choices concerning their daily life in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA interview, the licensee did not comply with the section cited above in that R1 reported they were confined to their room during the hours of 1pm-3pm, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
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Facility to submit LIC9098 self-ceritfying they will at all times provide for the personal rights of all residents, by plan of correction 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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
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Created By: Christi Coppo On 03/24/2026 at 02:35 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA interview and record review, the licensee did not comply with the section cited above in S2 did not have fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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Facility to self-certify on LIC9098 that S2 will not be present at the facility in any capacity until fingerprint clearance is obtained. LIC9098 due by plan of correction due date.
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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Based on LPA observation and record review, the licensee did not comply with the section cited above in that R1 had prescription for Doxycycline Monohydrate 100mg, that was not listed on the Centrally Stored Medication Log (CSML) and R3 did not have a CSML, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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Facility to submit plan to conduct medication training for a duration of no less than 2 hours. Training to be completed by no later than 4/7/26. Note: medication training completed for defiecncy of HSC1569.69 can also fulfill the plan of correction for this defiecny of 87456(h)(1)
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: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2026 03:56 PM - It Cannot Be Edited


Created By: Christi Coppo On 03/24/2026 at 02:35 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(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 LPA observation, the licensee did not comply with the section cited above in thatt LPA observed medication cabinet to be open and unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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Facility to self-certify on a LIC9098 that they will ensure medication cabinet remains locked and medications inaccessible to residents in care by plan of correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2026 03:56 PM - It Cannot Be Edited


Created By: Christi Coppo On 03/24/2026 at 02:35 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and interview, the licensee did not comply with the section cited above in that tile around kitchen sink is in disrepair and showing areas of black and gray substance, under kitchen sink mold all over: plywood has mold and has rotted, sides of the cabinet have mold, garbage disposal is rusted, and water lines rusted, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2026
Plan of Correction
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Facility to submit work order and paid invoice from professional repair company showing all mold has been removed, sink repaired and no longer leaking, disrepair bordering right hand side of sink repaired and free of black and gray substances by plan of correction due date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2026 03:56 PM - It Cannot Be Edited


Created By: Christi Coppo On 03/24/2026 at 02:35 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in that S6 did not have a health screen or TB clearance on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2026
Plan of Correction
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2
3
4
Facility to submit Health Screen and TB clearance for S6 to CCL by plan of correction due date.

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: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
Page: 9 of 14
Document Has Been Signed on 03/24/2026 03:56 PM - It Cannot Be Edited


Created By: Christi Coppo On 03/24/2026 at 02:35 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in that S6 did not have any training completed on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2026
Plan of Correction
1
2
3
4
Facility to submit training records for S6 in complaince with Health and Safety Code 1569.625(b)(1) by plan of correction due date, including required subject matters.

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: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
Page: 10 of 14
Document Has Been Signed on 03/24/2026 03:56 PM - It Cannot Be Edited


Created By: Christi Coppo On 03/24/2026 at 02:35 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in that S3, S4, and S5 did not have required restricted conditions training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2026
Plan of Correction
1
2
3
4
Facility to submit training log/certificates for S3, S4, and S5 showing completion of restricted conditions training by plan of correction due date.
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in that S5 and S6 did not have 10 hours of initial medication training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2026
Plan of Correction
1
2
3
4
Facility to submit training log/certificates for S5 and S6 showing completion of 10 hours of medication training by plan of correction due date.
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: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
Page: 11 of 14
Document Has Been Signed on 03/24/2026 03:56 PM - It Cannot Be Edited


Created By: Christi Coppo On 03/24/2026 at 02:35 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in that S3 and S4 did not have 8 hours of in-service medication training completed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2026
Plan of Correction
1
2
3
4
Facility to submit proof of 8 hours of medication training for S3 and S4 by plan of correction due date.
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in that LPA observed residents lying in bed staring at the wall or ceiling. No activites provided. LPA did not observe residents engaged in any activities for the duration of both LPA's visits, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
1
2
3
4
Facility to submit to CCL proof of purchase or pictures of items in use that provide cognitive, mental, or sensory stimulation for residents by plan of correction due date.
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: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
Page: 12 of 14
Document Has Been Signed on 03/24/2026 03:56 PM - It Cannot Be Edited


Created By: Christi Coppo On 03/24/2026 at 02:35 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(9)
General Food Service Requirements
(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in that LPA observed carton of 150 eggs left outside of refrigeration inside garage in 96 degree F heat, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
1
2
3
4
Facility to self-certify on a LIC9098 that they will store all food in a way that protects the safety and nuttritive value of the food by plan of correction due date.
Type B
Section Cited
CCR
87555(b)(21)
General Food Service Requirements
(21) Freezers of adequate size shall be maintained at a temperature of 0 degree F (-17.7 degree C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degree F. (4 degree C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and interview, the licensee did not comply with the section cited above in that LPA observed refrigerator in garage containing food to not be cool and was leaking, no thermostat present, so no temperature reading available. Facility has two [2] refrigerators and one freezer. Per designee, the other refrigerator has also been leaking and licensee is aware, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
1
2
3
4
Facility to submit proof of purchase or proof of repair of refrigerators by plan of correction due date. Invoce or work order will be accepted as proof of purchase or repair.
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: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
Page: 13 of 14
Document Has Been Signed on 03/24/2026 03:56 PM - It Cannot Be Edited


Created By: Christi Coppo On 03/24/2026 at 02:35 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in that R1 has full bed rails on bed but no exception on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
1
2
3
4
Facility to submit proof of removal of full bed rails for R1 by plan of correction due date. Pictures will be accepted as proof.
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: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
Page: 14 of 14