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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126890101
Report Date: 07/16/2024
Date Signed: 07/16/2024 11:33:27 AM


Document Has Been Signed on 07/16/2024 11:33 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:
126890101
ADMINISTRATOR:SMITH, CLEOFACILITY TYPE:
740
ADDRESS:6449 PURDUE DRTELEPHONE:
(707) 442-3656
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:4CENSUS: 4DATE:
07/16/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Cleo SmithTIME COMPLETED:
11:45 AM
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At approximately 8:20AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a pre-licensing inspection. LPA met with Administrator Cleo Smith and explained the purpose of the visit. Administrator certificate is current. LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident records are secure. First Aid/CPR certification was current. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required seven-day non-perishable and two day perishable supply of food. Medication is locked and not accessible. The facility was observed to be at a comfortable temperature. First aid kit was present. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. Facility conducts emergency drills quarterly. LPA received evidence of Liability insurance at the time of visit.

Component III orientation was conducted at facility. Applicant conveyed a good knowledge of Title 22 regulations.



LPA will submit the application packet for a final review and approval from the Licensing Program Manager.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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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