<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803838
Report Date: 10/10/2023
Date Signed: 10/10/2023 10:18:44 AM


Document Has Been Signed on 10/10/2023 10:18 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:ROSELAND CARE HOMEFACILITY NUMBER:
126803838
ADMINISTRATOR:SMITH, CLEOFACILITY TYPE:
740
ADDRESS:6449 PURDUE DRTELEPHONE:
(707) 442-7330
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:6CENSUS: 4DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Kiko SmithTIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with Licensee Kiko Smith. At approximately 9:00AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored and not accessible. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.
At approximately 9:15AM, LPA reviewed 4 resident records and 2 staff records. LPA found records contained current and signed admission agreements, physician reports, resident appraisals and physician orders. Medication records are thorough and contained physician's orders for each resident. Evidence of current first aid and CPR training were current in staff files reviewed.
At approximately 10:00AM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 7/1/2023.
LPA received updated liability insurance documentation.
No citations issued during this visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
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 1