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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802017
Report Date: 08/16/2022
Date Signed: 08/16/2022 02:39:40 PM

Document Has Been Signed on 08/16/2022 02:39 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: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:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Toni Pump (staff)TIME COMPLETED:
02:54 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required – 1 yr. Infection Control inspection to this facility. LPA were greeted by staff Toni Pump. Licensee, Pam Johnson was not able to come to the facility, but was available by phone and gave authorization to staff to sign the report.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that facility have posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/staff conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene and paper products. Commonly touched surfaces are disinfected at least three times a day. Each resident has their own room in case that needs to isolate and the facility is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and N-95 fit tested. Staff and residents are being monitored daily and results are documented. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate and received boosters for staff and residents. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. Residents receive indoor visitation with their families and facility is able to perform antigen tests to visitors as well as screening, documenting for symptoms and tracking purposes. Facility has submitted their Covid Mitigation Plan it was approved on 1/20/21 and their Infection Control Plan to CCL for review. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) and supplies are accessible for staff. At approximate 1:38pm LPA/staff observed that 2 out of 2 fire extinguishers were last serviced on August 31, 2020.

Facility provided updated copies of the following: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Liability insurance and Emergency Disaster Plan (LIC610E).

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies) may result in a civil penalty assessment.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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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Document Has Been Signed on 08/16/2022 02:39 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/16/2022 at 02:05 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: WILD ROSE LIVING
FACILITY NUMBER: 496802017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203

87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 2 out of 2 fire extinguisher was charged but not serviced which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2022
Plan of Correction
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Licensee to contact Fire Department or Fire Safety company to have the fire extinguishers serviced. Licensee to submit copy of invoice/receipt and pictures of newly dated tags 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:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


LIC809 (FAS) - (06/04)
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