<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804035
Report Date: 03/07/2025
Date Signed: 03/07/2025 01:20:41 PM

Document Has Been Signed on 03/07/2025 01:20 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:ROSES RESTHOMEFACILITY NUMBER:
216804035
ADMINISTRATOR/
DIRECTOR:		DANIEL, SILVANAFACILITY TYPE:
740
ADDRESS:1 ROOSEVELT AVETELEPHONE:
(415) 479-5522
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 8CENSUS: 4DATE:
03/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Administrator Silvana DanielTIME VISIT/
INSPECTION COMPLETED:
01:30 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
At approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz and Licensing Program Manager (LPM) Victoria Bertozzi arrived unannounced to conduct a 1-Year Required Visit and met with Staff Member, Elma Cordero. Licensee/Administrator, Silvana Daniel arrived shortly during the visit. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 8 non-ambulatory residents. Facility has an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there were 4 Residents in care and 1 staff member on-site.

At approximately 9:45AM, LPA/Administrator toured the building and did following observations; grounds which was found to be clean and in good repair. Facility had emergency lighting. Facility is a 1 story building with 7 Resident bedrooms, 1 staff bedroom, 4 bathrooms, and common spaces. Facility has an Infection Control plan on file. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area.

During walk-though LPA/Administrator observed cleaning supplies were accessible to residents in kitchen cabinet under the sink was unlocked and containing cleaning supply. Also, cabinet in the laundry room were containing cleaning supply and lock weren't properly functioning(Citation given). Licensee agrees to remove the cleaning supply under the sink to the laundry cabinet and fix the lock. The facility has a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility kitchen, refrigerators and freezers were clean, and food was stored per regulation. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present.

Continued on LIC809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 03/07/2025 01:20 PM - It Cannot Be Edited


Created By: Ali Deniz On 03/07/2025 at 12:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ROSES RESTHOME
FACILITY NUMBER: 216804035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs/Administrator observation and interview, the licensee did not comply with the section cited above in cleaning supplies were accessible to residents in kitchen cabinet under the sink was unlocked and containing cleaning supply. Also, cabinet in the laundry room were containing cleaning supply and lock weren't properly functioning which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2025
Plan of Correction
1
2
3
4
Licensee agrees to remove the cleaning supply under the sink to the laundry cabinet and fix the lock. Licensee will submit pictures to clear capitation by plan of correction date 03/08/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Ali Deniz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/07/2025 01:20 PM - It Cannot Be Edited


Created By: Ali Deniz On 03/07/2025 at 12:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ROSES RESTHOME
FACILITY NUMBER: 216804035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs/Administrator observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 2 staff did not have the health screening completed as required by the Health and Safety Code, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
1
2
3
4
Licensee agree to submit the health screening report to the CCL as required by Health and Safety Code by by plan of correction date 03/28/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Ali Deniz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ROSES RESTHOME
FACILITY NUMBER: 216804035
VISIT DATE: 03/07/2025
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
26
27
28
29
30
31
32
Continued from LIC809C

Water temperature measured 114.2 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire extinguishers inspected and charged/last inspected 11/01/2024. Carbon Monoxide detectors were present. Medication is centrally stored and secure.



At approximately 11:10AM, LPAs reviewed 4 resident files and all found to be in order and have updated documents on file. Medication records are contained physician's orders for each resident per regulation. Hospice care plans were up to date for each hospice resident.

At approximately 11:45AM, LPAs reviewed 2 staff records. LPA observed 1 out of 2 staff files did not have the health screening completed as required by the Health and Safety Code (Citation given).
Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 01/20/2025.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC308 – Designation of Facility Responsibility
LIC500 - Personnel Report
LIC610E - Emergency Disaster Plan
Evidence of Updated Liability Insurance


Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4