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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804035
Report Date: 03/16/2022
Date Signed: 03/16/2022 01:05:33 PM


Document Has Been Signed on 03/16/2022 01:05 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:ROSES RESTHOMEFACILITY NUMBER:
216804035
ADMINISTRATOR:DANIEL, SILVANAFACILITY TYPE:
740
ADDRESS:1 ROOSEVELT AVETELEPHONE:
(415) 479-5522
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:8CENSUS: 5DATE:
03/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Care Giver, Elma Cordero
Administrator, Silvana Daniel
TIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Roses Resthome for the purpose of conducting a Pre-Licensing Inspection. LPA was greeted at the door by Care Giver, Elma Cordero. Facility is approved for 8 non-ambulatory residents. Administrator, Silvana Daniel arrived 10 minutes later.

LPA toured the facility with Administrator, Silvana Daniel. Facility was found to be clean and at a comfortable temperature. Fire Extinguisher was found to be last charged on January 2022. Facility smoke detectors and Carbon Monoxide detectors were observed and operational during the inspection. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured at 114 degrees F within acceptable range of 105 to 120 degrees. Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. Food is available for residents any time of the day. Toxins are stored in a locked laundry room cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. During the Pre-Licensing inspection, LPA obtained the most up-to-date Liability insurance. LPA also obtained a copy of the Administrator Certificate along with a First Aid, CPR and AED certificate.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the medicine cabinet. Staff have had all PPE training. Mitigation Plan reviewed at the facility with the Administrator. Emergency disaster plan was discussed with the Administrator during the Pre-Licensing inspection. Component III was completed with the Administrator during the Pre-Licensing inspection. Exit interview was conducted, and a copy of this report emailed to the Administrator. LPA will forward report to the assigned Application Analyst in our Department; The Application Analyst will notify the Applicant of the status of the application.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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