210111734-11-9-2023-21-AS-HRUS-CXETFE-20231109134124

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210111734
Report Date: 11/09/2023
Date Signed: 11/09/2023 01:41:30 PM

Document Has Been Signed on 11/09/2023 01:41 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 RCFE		FACILITY NUMBER:	210111734
ADMINISTRATOR:	ALLEN, C. ELIZABETH		FACILITY TYPE:	740
ADDRESS:	256 SUNSET PARKWAY		TELEPHONE:	(415) 264-7399
CITY:	NOVATO	STATE: CA	ZIP CODE:	94945
CAPACITY:	6	CENSUS: 6	DATE:	11/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Caregiver, Gladys Flores		TIME COMPLETED:	02:00 PM

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	Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct an Annual Required inspection and was greeted by staff. LPA met with Caregiver, Gladys Flores. LPA initiated a tour of the facility around 9:20AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Staff bedroom was locked and inaccessible to clients. Six of six resident beds are equipped with half rails. Physicians reports reflected the need for half rails for mobility. LPA discussed with staff that physician is to fill out the report. Water temperature in bathrooms used by residents measured at 123 and 116 degrees F. Sink closest to water heater was not within the range of 105 to 120 degrees F allowed per regulation. LPA requested water heater be turned down slightly, and staff immediately turned down water heater. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were located in garage and locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Facility has a pool in backyard that is fenced and locked. Emergency food and water supplies are stored in the garage. Facility has extra Personal Protective Equipment upon entry. Fire extinguishers were last serviced August 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational during inspection. Fire/disaster drills are being conducted quarterly with the last one conducted July 2023. Continued on LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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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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
	VISIT DATE: 11/09/2023

NARRATIVE

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Continued from LIC 809

Five staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed. Administrative Certificate for Administrator, Elizabeth Allen, 6000978740 expired 10/19/2023. Administrator has sent in all required recertification paperwork. Medications and medication records were reviewed.

Administrator to submit updates of the following documents by 12/09/2023:
Admission Agreement
Personnel Report (LIC 500)
Liability Insurance
Infection Control Plan (If any changes)
Emergency Disaster Plan (If any changes)

No deficiencies cited during this inspection.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC809 (FAS) - (06/04)

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