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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802017
Report Date: 10/17/2023
Date Signed: 10/17/2023 11:58:19 AM

Document Has Been Signed on 10/17/2023 11:58 AM - 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:PUMP, TONI LFACILITY TYPE:
740
ADDRESS:1172 WILD ROSE DRIVETELEPHONE:
(707) 578-0392
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 5DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Alberto Aparicio (staff)TIME COMPLETED:
12:13 PM
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Licensing Program Analyst (LPA) Cuadra arrived unnanounced to conduct a Required Annual Inspection and met with Alberto Aparicio (caregiver). Pamela Johnson (Licensee) was not able to come to the facility, but was available by phone and gave authorization for staff to sign the report. There is currently no residents in hospice and residents with a diagnosis of dementia. Required postings were observed. All fees are current as of this time.

LPA/staff toured the facility grounds inside and outside and made the following observations: Facility was a comfortable temperature with thermostat reading at 78 degrees F. Passageways were free from obstructions. Resident rooms were furnished per regulation. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Medications were centrally stored and locked. Fire extinguisher was last inspected May 2023. Smoke and Carbon Monoxide detectors were tested during inspection and operational. Exit doors have auditory alert system that were functional at time of visit. Last Disaster Drill was conducted on June 16, 2023. Licensee agreed to conduct a disaster drill every quarter as stated per regulation. A technical advisory will be issued. Cleaning supplies were not accessible to residents in care. Knives are located in a locked closet in the kitchen. Facility has at least two days of perishable & one week of non-perishable foods.

At approximate 9:00am LPA/staff observed water temperature in resident's bathrooms measured at 121.1, 121.5 & 121.6 which are not within allowable range of 105 to 120 degrees F in faucets used by residents.

Continue on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 496802017
VISIT DATE: 10/17/2023
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Continued from LIC809...

At approximate 9:30am LPA/staff observed main fridge located in the facility kitchen was locked. Per staff, they do lock it due to resident's behavior to wake up at night and opens the fridge. LPA discussed with Licensee that a waiver request needs to be submitted to the Department for review and approval if they wish to have a locked fridge, outlining why the refrigerator needs to be locked and how adequate and readily available snacks and beverages will be provided to residents. Licensee agreed a waiver request and its supporting documents would need to be submitted to the Department. LPA observed staff removed the lock from the main fridge during visit. Resident's daily care notes are updated.

File review was initiated at 10:30 am. Five resident files were reviewed. All residents files have current medical assessments and needs appraisals/care services plans updated. Staff on duty have required First aid and CPR certificate updated. However, Licensee informed LPA that all staff records were locked in the facility office. LPA will return to review staff files to ensure that staff have their files current. Administrator Certificate for Pamela Johnson 6018738740 expires 7/27/24. Medications and medication records were reviewed.

Licensee agreed to submit updates of the following documents by 10/31/2023: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), control of property and liability insurance.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights given.

Exit interview conducted with staff, Licensee was aware of deficiencies via phone and copy of report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/17/2023 11:58 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 10/17/2023 at 11:17 AM
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: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observations, the licensee did not comply with the section cited above in three out of three bathrooms used by residents the water temperature measured 121.1, 121.5 and 121.6 F degrees, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2023
Plan of Correction
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Facility to ensure hot wate rtemperature is maintainted within regulation - 105 to 120 F. Facility to submit a LIC 9098 self certification that hot water has been adjusted to be within regulation by POC date to clear citation.
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: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/17/2023 11:58 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 10/17/2023 at 11:17 AM
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: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observation, record review and interviews with licensee, the licensee did not comply with the section cited above in having all staff records available for LPA's review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee agreed to have records current and maintained for LPA's review. LPA will return to the facility to review staff records.
Type B
Section Cited
CCR
87555(b)(3)

87555 General Food Service Requirements (b) The following food service requirements shall apply: (3) Between-meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interview's with staff, the licensee did not comply with the section cited above in main refrigerator used by resident's in care was locked, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee shall submit a request for a waiver to have a locked refrigerator outlining why the refrigerator needs to be locked and how adequate and readily available snacks and beverages will be provided to clients per Title 22 Regulation by POC 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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
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