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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803588
Report Date: 03/20/2026
Date Signed: 03/20/2026 12:06:05 PM

Document Has Been Signed on 03/20/2026 12:06 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:COUNTRY ROSE ASSISTED LIVINGFACILITY NUMBER:
496803588
ADMINISTRATOR/
DIRECTOR:		ARCHER, LEAHFACILITY TYPE:
740
ADDRESS:2273 WEST HEARN AVENUETELEPHONE:
(707) 495-0801
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6CENSUS: 4DATE:
03/20/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:24 AM
MET WITH:Rosa Ascencio (staff)TIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with staff, Rosa Ascencio. Licensee, Leah Archer came to the facility and gave permission for caregiver to sign report. Annual fees are current. No residents receiving hospice.

LPA/staff initiated a tour of the facility at 9:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathroom measured at 117.3 degrees F which is within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required grab bars. Kitchen cabinet containing cleaning supplies was locked. Medications were centrally stored and locked. Fire extinguisher charged and serviced as of July 2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have auditory alerts that were functional at time of visit. Last disaster drill was conducted on January 2026. Facility has at least two days of perishable and one week of non-perishable foods. However, LPA have a conversation with Licensee about having different fruit options other than strawberries, bananas and oranges. Required postings observed. Emergency supply of non-perishable food and water for at least 72 hours of shelter is available.

At approximately 9:30am, LPA/staff observed ceiling located in the living room needs patchwork. According to staff, the Licensee has a contractor who will come to do the repairs.
Continues on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: COUNTRY ROSE ASSISTED LIVING
FACILITY NUMBER: 496803588
VISIT DATE: 03/20/2026
NARRATIVE
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Continued from LIC809...

File review was initiated at 10:00 am. Two staff files and four resident files were reviewed. Two out of five residents (R1 and R2) care plan needs to be signed by resident's responsible parties. One out of two staff (S1) did not have health screening and TB results. Staff have required First Aid and CPR certificates. Training hours were complete. Resident (R2) does not have a half bed rails order on file. There was no LIC9020 Register of facility clients/residents available (technical violation issued). LPA reviewed incident records on file are in compliance with reporting requirement regulations.

At approximately 10:25am Administrator certificate for Administrator Leah Archer # 7009822740 expired on 12/23/24. LPA reviewed and confirmed that Administrator is not currently in any of the Department's list for review. Staff contacted Licensee and LPA spoke with Licensee where it was determined that Licensee has not submitted an updated application to have their certificate renewed.

At approximately 11:17am, LPA/staff conducted review of medications and their records. A spot check of medications revealed that medication logs (R1, R2 & R3) have not been updated into Centrally Stored Medication Log.

Licensee to submit updates of the following documents by 4/3/2026: copy of Liability Insurance.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with staff, Licensee was notified about deficiencies found during today's visit and a copy of the report was given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/20/2026 12:06 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/20/2026 at 11:40 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: COUNTRY ROSE ASSISTED LIVING
FACILITY NUMBER: 496803588

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observation and interview, the licensee did not comply with the section cited above by ceiling needs patchwork which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee agrees to submit pictures as proof of repairs needed were resolved to CCL by POC due date to clear the citation.
Type B
Section Cited
CCR
87412(a)(11)
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: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in one out of three staff did not have health screening including TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee agrees to submit proof that staff (S1) has a health screning including TB test on file by POC due date to clear the citation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/20/2026 12:06 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/20/2026 at 11:40 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: COUNTRY ROSE ASSISTED LIVING
FACILITY NUMBER: 496803588

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observation, records review and interview, the licensee did not comply with the section cited above by not obtaining a valid administrator certification after their certificate expired in 2024, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee agreed to submit supporting documentation to the Department's certification unit and will send proof of submission to CCL by POC due date to clear the citation.
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onLPA's/staff observation, interview and record review, the licensee did not comply with the section cited above by not maintaining a Centrally Stored Medication Log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Facility to review and update the Centrally Stored Medication Log by POC due date, 4/3/2026 to clear the citation and will submit self-certification form that all resident's medications were updated in the CSMD to clear the citation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/20/2026 12:06 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/20/2026 at 11:40 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: COUNTRY ROSE ASSISTED LIVING
FACILITY NUMBER: 496803588

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(i)
Reappraisals
(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in two out of four resident's care plans where not signed by their responsible parties which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee agreed to review care plans with resident's responsible parties and will submit to CCL a self-certification form ensuring that care plans have been signed by POC due date 4/3/26.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in one out of four residents do not have a bed rail form on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee agrees to obtain bed rail order for resident (R2) and will submit to CCL self-certification form (LIC 9098) certifying that bed rail order for R2 is on file.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2026


LIC809 (FAS) - (06/04)
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