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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210111734
Report Date: 12/16/2022
Date Signed: 12/16/2022 02:33:50 PM


Document Has Been Signed on 12/16/2022 02:33 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:WILD FLOWERS RCFEFACILITY NUMBER:
210111734
ADMINISTRATOR:ALLEN, C. ELIZABETHFACILITY TYPE:
740
ADDRESS:256 SUNSET PARKWAYTELEPHONE:
(415) 264-7399
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY:6CENSUS: 5DATE:
12/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:59 PM
MET WITH:Caregiver, Gladys FloresTIME COMPLETED:
02:43 PM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Caregiver, Gladys Flores.

During complaint investigation LPA discovered that facility has two hospice residents but only has a waiver for one. Recently facility had three hospice residents at one time. Additionally, the facility has a resident who is bedridden but facility does not have a bedridden fire clearance.

In order to request a bedridden fire clearance, the following documents are to be sent to CCL no later than 12/17//2022:
  • An LIC200 filled out entirely showing 1 bedridden in section 10B
  • An updated facility sketch identifying bedridden room.


In order to request an hospice increase, the following documents are to be sent to CCL no later than 12/17/2022:
  • A written request for hospice increase to the Department that includes the specific maximum number of terminally ill residents which the facility wants to have at any one time, a statement by the licensee that they have read, Section 87633, Hospice Care for Terminally Ill Residents, this section and all other requirements within Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly and that they will comply with these requirements, a statement by the licensee that the terms and conditions of all hospice care plans which are designated as the responsibility of the licensee, or under the control of the licensee, shall be adhered to by the licensee and a statement by the licensee that an agreement with the hospice agency will be entered into regarding the care plan for the terminally ill resident to be accepted and/or retained in the facility. The agreement with hospice shall design and provide for the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the licensee.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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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Document Has Been Signed on 12/16/2022 02:33 PM - It Cannot Be Edited

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: WILD FLOWERS RCFE
FACILITY NUMBER: 210111734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2022
Section Cited

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87606 Care of Bedridden Residents
To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). Requirement has not been met as evidenced by: Based on document
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Facility agrees to submit an updated LIC200 and Faciilty sketch as described in the LIC809 by POC due date, 12/17/2022.
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review, Licensee did not comply with the above regulation by retaining a bedridden resident without an approved bedridden fire clearance. This is an immediate risk to the health and safety of residents in care.
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Type A
12/17/2022
Section Cited

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87632 Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request
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Facility agrees to submit a request for a hospice waiver increase to CCL by POC due date, 12/17/2022.
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retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. Requirement has not been met as evidenced by: Based on document review facility has 2 hospice residents but are only approved for one. This is an immediate risk to the health and safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
LIC809 (FAS) - (06/04)
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