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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802017
Report Date: 07/21/2021
Date Signed: 07/21/2021 01:53:11 PM

Document Has Been Signed on 07/21/2021 01:53 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:WILD ROSE LIVINGFACILITY NUMBER:
496802017
ADMINISTRATOR:JOHNSON, PAMELAFACILITY TYPE:
740
ADDRESS:1172 WILD ROSE DRIVETELEPHONE:
(707) 578-0392
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 6DATE:
07/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Toni Pump, CaregiverTIME COMPLETED:
02:15 PM
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Licensing Program Analysts (LPAs) Lopez and Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility. LPAs were greeted by caregiver Toni Pump. Licensee, Pamela Johnson was available by phone and gave permission for caregiver to sign report. LPAs conducted a Risk Assessment call with Toni Pump prior to the visit. There were 6 residents in care present at the facility.

LPAs arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPAs continued tour of the facility on July 21, 2021. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on August, 2020 at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. There was sufficient amount of supply for both perishable and nonperishable foods 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. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available.

Facility has submitted a mitigation program plan that has been approved 1/20/21. Per licensee, all staff have been vaccinated. All residents are vaccinated except one. Posters have been placed at entrance, and facility entrance area has a designated area to screen visitors, thermometer and other items designated for visitors and staff before coming into work. Staff and residents are being monitored daily and results are documented in a binder for each month. Facility has PPE supplies stored in the storage room. Facility has a 30-day supply of medication for residents. Residents do not typically wear masks inside the facility but have them available. Facility has conducted staff training on infection control.

No deficiencies observed or cited during today's Required 1- Year inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2021
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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