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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804035
Report Date: 03/13/2023
Date Signed: 03/13/2023 11:04:02 AM


Document Has Been Signed on 03/13/2023 11:04 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: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:
03/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Silvana Daniel (Licensee)TIME COMPLETED:
11:18 AM
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Licensing Program Analyst (LPA) Marisol Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee, Silvana Daniel.

Upon arrival, LPA observed that staff continue to wear masks per current guidance. LPA discussed the recent PIN that allows facilities to discontinue Covid-19 screening. LPA/Licensee initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in client bathroom measured at 108.7 and 112.1 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Kitchen cabinet containing cleaning supplies and disinfectant was 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. Fire extinguisher was last inspected December 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. Most recent fire/disaster drill was conducted February 3, 2023. Three staff files and four out of five client files were reviewed. One resident just moved-in as of yesterday and file is in progress to be set-up with required documentation. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator Silvana Daniel 6003231740 expires 3/21/2023. Medications and medication records were reviewed. No cash resources are being handled. LPA conducted staff and residents interviews.
Licensee and LPA discussed their Emergency Disaster Plan and Infection Control Plan. Licensee agreed to submit updates of the following documents by 4/09/2023: LIC 500 Personnel Summary, LIC 610 Emergency Disaster Plan (review and submit If changes), Infection Control Plan (review and submit If there any changes), LIC 9020 Register of Facility Client’s/Resident’s, Liability Insurance, LIC 308 Designation of facility responsibility.

No deficiencies cited during this inspection
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2023
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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