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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803886
Report Date: 02/24/2022
Date Signed: 02/24/2022 02:56:02 PM

Document Has Been Signed on 02/24/2022 02:56 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:H & M'S THE ROSE GARDENFACILITY NUMBER:
496803886
ADMINISTRATOR:GARCIA, MAGGIEFACILITY TYPE:
740
ADDRESS:2370 MELBROOK WAYTELEPHONE:
(707) 546-2429
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: 5DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Heherson and Maggie GarciaTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 1:30 PM, and met with licensee/administrator Heherson and Maggie Garcia. The inspection is focused on the Infection Control procedures and practices of this facility. LPA was initially greeted by staff, licensee/administrator arrived shortly.

Upon entry LPA was screened for COVID symptoms and asked to sign in by staff. At primary entrance LPA observed visitor sign-in sheet. LPA conducted walk through of the facility with licensee/administrator and observed COVID postings throughout. Mitigation plan was submitted by licensee and reviewed by Community Care Licensing.

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. There is an information resource binder available for review with PINs . Staff have completed Personal Protective Equipment (PPE) and infection control training through local public health. Staff have been N95 fit tested. High touch surface areas are disinfected daily. Due to current facility census residents could isolate in their own rooms if they became ill. LPA observed COVID kit with PPE to support a resident in isolation. Residents are screened daily for symptoms, LPA observed screening logs.

Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible to residents. Medications are centrally stored and inaccessible to residents. All residents have received their booster shot. All staff have received their booster shot. Facility is not currently conducting surveillance testing.

Continued on LIC 809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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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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: H & M'S THE ROSE GARDEN
FACILITY NUMBER: 496803886
VISIT DATE: 02/24/2022
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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing.

LPA and administrator/licensee discussed visitation and provided guidance to review PIN 22-07 regarding visitation.

LPA requested the following documents during the visit:

LIC 500
LIC 308
Liability Insurance
Emergency Disaster Plan
Administrator Certificate

No deficiencies cited during this inspection.

Exit interview conducted with licensee/administrator. LPA unable to print, will email report to licensee.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC809 (FAS) - (06/04)
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