<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802017
Report Date: 10/01/2021
Date Signed: 10/01/2021 02:28:11 PM

Document Has Been Signed on 10/01/2021 02:28 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:
10/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rawanda Perez (Staff) TIME COMPLETED:
02:30 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) Cuadra conducted an unannounced case management inspection and was greeted by staff, Rawanda Perez; Licensee was not able to come to the facility, but gave authorization for staff to sign the report. LPA conducted risk assessment with staff prior to make the visit. The purpose of this case management inspection is to follow up on a self reported incident report submitted to Community Care Licensing (CCL) and SOC 341 submitted to CCL on 9/27/2021.

On 9/15/21 LPA received a call from Licensee, Pamela Johnson notifying CCL about the incident where staff (S1) witnessed a possible financial abuse. Licensee agreed to submit a self incident report and SOC341 to CCL within the next 7 days. On 9/27/21 CCL received self reported incident report and a SOC 341 reporting possible financial abuse. S1 reported to Licensee that on 8/6/21 individual (I1) came to visit resident (R1) and S1 overheard I1 was requesting R1 to write down a password for a Cash application and was asking to take R1 out of the facility. S1 notified R1's responsible party and Licensee. Per Licensee, Responsible party instructed the facility staff that if I1 comes back to the facility to visit R1 to call the cops and so far no amount of money has been reported lost or missing. This facility does not handle cash for residents in care.

Licensee completed SOC 341 and submitted to CCL and Ombudsman. On 9/30/21 LPA cross reported incident with APS and Long Term Ombudsman.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2021
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 1