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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802017
Report Date: 09/10/2024
Date Signed: 09/10/2024 11:40:19 AM

Document Has Been Signed on 09/10/2024 11:40 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/
DIRECTOR:		PUMP, TONI LFACILITY TYPE:
740
ADDRESS:1172 WILD ROSE DRIVETELEPHONE:
(707) 578-0392
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 5DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Toni Pump (Administrator)TIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Cuadra arrived unnanounced to conduct a Required Annual Inspection and met with Toni Pump, Administrator. There is currently one resident receiving hospice services and residents with a diagnosis of dementia. Annual fees are current.

LPA/Administrator toured the facility inside, outside and made the following observations: Facility was a comfortable temperature with thermostat reading at 70 degrees F. Passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathrooms measured at 113.7, 113.5 and 112.9 which are within allowable range of 105 to 120 degrees F in faucets used by residents. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. 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 and one week of non-perishable foods. Medications were centrally stored and locked. Fire extinguisher was last inspected May 2024. Smoke and Carbon Monoxide detectors were tested during inspection and operational. Exit doors have auditory alert system that were functional at time of visit. The facility have not conducted a disaster drill within the last quarter (technical violation was issued). Medications and medication records were reviewed. Required postings observed.

LPA initiated file review at 10:00 am. Five resident and three staff files were reviewed. One out of five residents needs appraisals/needs and services plans to be updated (technical violation issued). Staff have required First aid and CPR certificates and required additional training hours completed per regulation. Continue on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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: 09/10/2024
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Continued from LIC809...

Administrator Certificate for Pamela Johnson 7005563740 is showing as pending in the Department's list of renewal of administrator's certificate. However, LPA was informed that the facility will be submitting required documentation to appoint a new administrator. LPA provided in this report documentation needed to appoint a new administrator as follow: LIC 200 (original - must be mailed or delivered to the Regional Office), LIC 308 Designation of Facility responsibility (designation of who is the administrator), Copy of current Administrator Certificate, Administrator Resume (if possible), LIC 501 Personnel Record, LIC 500 Personnel Report (indicating you as administrator with your schedule), Copy of Personal ID and Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations).

Licensee/Administrator agrees to submit updates of the following documents by 9/17/2024:
- Designation of Administrative Responsibility (LIC308)
- Personnel Report (LIC500)
- Control of property.
- Copy of Liability Insurance Certificate.

No deficiencies cited during today's inspection. Exit interview was conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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