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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804075
Report Date: 03/18/2025
Date Signed: 03/18/2025 03:21:59 PM

Document Has Been Signed on 03/18/2025 03:21 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WINDROSE CARE HOMEFACILITY NUMBER:
496804075
ADMINISTRATOR/
DIRECTOR:		SOLOMON, BANAFACILITY TYPE:
740
ADDRESS:1759 WINDROSE LANETELEPHONE:
(707) 852-5025
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 6DATE:
03/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Bana Solomon-AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analysts (LPA) Alviso conducted a Required- 1 Year visit, on 3/18/25 at approximately 10am, and was greeted by staff. There were three (3) staff on duty, lead caregiver Ana, and caregivers Roxanna and Yadira. Administrator was contacted by staff, and arrived shortly after to meet with the LPA.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for six (6) residents. Facility has a required infection control plan. Facility has a required emergency and disaster plan. The facility does have emergency food, water, and supplies to meet the "72 hour shelter in place" requirements.
Facility has a fire clearance approval for a total of six non-ambulatory, of which one (1) may be bedridden. Fire extinguishers were serviced and tagged. Facility has a carbon monoxide detector that worked properly during the inspection. All smoke alarms are hard wired and worked properly during the inspection. All exits were clear and unobstructed. Per review of records, emergency disaster drills have been conducted as required; Last quarterly drills documented drills were conducted on 6/12/24 and 9/18/24.

LPA toured the facility with the Administrator. The bathrooms had grab bars and non-slip mats/flooring for resident use. The hot water was checked at 116. degrees Fahrenheit, which is within regulation. There was a sufficient supply of furnishings for resident use. Sufficient supply of linens, cleaners/soap/disinfectants, hygiene products, paper products, and personal protective equipment (PPE) supplies. The LPA observed that the home was at a comfortable temperature for residents in care. There was sufficient lighting in all resident rooms, hallways, bathrooms, and common areas. Sufficient food supply. The facility was observed to be clean and orderly. Medications were centrally stored and locked making them inaccessible to residents in care. Disinfectants/cleaners were observed to be locked up and inaccessible to the residents in care. The backyard was observed to be clean, orderly, and all pathways clear and free of obstruction. Fire exit gate was clear and unobstructed. There is patio furnishing available in the backyard for resident use.
Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WINDROSE CARE HOME
FACILITY NUMBER: 496804075
VISIT DATE: 03/18/2025
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LPA reviewed six (6) resident files, including medical assessments and medications. All files were complete.

LPA reviewed five (5) staff files. All staff have required criminal record clearance. Staff have required training. Staff have required first aid and CPR certification.

LPA is requesting the following documents be updated and submitted by 4/18/25.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required- submit copy of review page or if changes submit copy of the plan.
Infection Control Plan (ensure to review and update as needed/required- submit copy of review page or if changes submit copy of the plan.
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate.

There are no deficiencies cited today.
Exit interview was conducted with Administrator Bana Solomon.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC809 (FAS) - (06/04)
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