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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803838
Report Date: 08/04/2022
Date Signed: 08/04/2022 03:23:25 PM


Document Has Been Signed on 08/04/2022 03:23 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:ROSELAND CARE HOMEFACILITY NUMBER:
126803838
ADMINISTRATOR:SMITH, CLEOFACILITY TYPE:
740
ADDRESS:6449 PURDUE DRTELEPHONE:
(707) 442-7330
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:6CENSUS: 6DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Rolonda ReynoldsTIME COMPLETED:
03:40 PM
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At approximately 2:45 PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an Annual Required infection control inspection. This inspection will focus on the Infection Control procedures and practices of this facility. LPA met with Caregiver Rolonda Reynolds and toured the facility.
Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident restrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be charged and inspected within the last 12 months. Facility Posters are in place at the entrance and throughout the building. The entrance area has a small table with hand sanitizer, thermometer and other items designated for visitors and staff before coming into work or visit. Facility has PPE supplies. Residents do not wear masks inside the facility but have them available. LPA observed Staff were wearing masks during this visit.

There were no deficiencies found in the areas inspected.

No citations issued.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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