216804035-3-24-2026-21-AS-CFES-DSGVYJ-20260324165114

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804035
Report Date: 03/24/2026
Date Signed: 03/24/2026 04:51:34 PM

Document Has Been Signed on 03/24/2026 04:51 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 RESTHOME		FACILITY NUMBER:	216804035
ADMINISTRATOR/ DIRECTOR:	DANIEL, SILVANA		FACILITY TYPE:	740
ADDRESS:	1 ROOSEVELT AVE		TELEPHONE:	(415) 479-5522
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY: 8		CENSUS: 7	DATE:	03/24/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:10 PM
MET WITH:	Licensee, Silvana Daniel		TIME VISIT/ INSPECTION COMPLETED:	05:00 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	At approximately 12:10PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Staff Members, Elma Cordero and Elijha Cintron. Licensee/Administrator, Silvana Daniel arrived at approximately 12:20PM. 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 7 Residents in care and 2 staff members on-site. At approximately 12:15PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Licensee/Administrator and observed the following: facility was found to be clean and at a comfortable temperature with all exits free from obstruction. 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. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. LPA observed instances of unlabelled or expired foods in facility fridge. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Facility's cleaning supplies and laundry detergent were observed to be accessible during visit in laundry room. It was observed that facility has a cabinet for cleaning supplies but it was unlocked with the key attached during visit. Facility's fire extinguishers was last inspected November 2025. Facility's last emergency/disaster drill was conducted January 2026. Facility's emergency disaster plan was last reviewed and updated on 03/01/2026. LPA reviewed 2 staff files and 4 resident files. LPA also reviewed resident medication. Staff files had current First Aid/CPR Continued on LIC809

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: ROSES RESTHOME	FACILITY NUMBER: 216804035
	VISIT DATE: 03/24/2026

NARRATIVE

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Continued from LIC809

certification. Review of Staff Member 1's (S1) file was found to be missing proof of health screening. Review of last year's annual visit indicated that S1 did have a health screening on file but Licensee was unable to locate it during this year's annual visit. Review of Staff Member 2's file (S2) was found to be missing proof of their initial 40 hours of training. 1 of 4 resident files were found to be missing an updated needs/services plan. It was observed that another resident is considered bedridden per their medical assessment. Further review showed that this resident is receiving hospice services and facility sent notification to the Marin Fire Department. Facility to clarify fire clearance with Marin Fire Department and to submit an updated facility sketch to Community Care Licensing by 04/03/2026.

LPA conducted review of resident medication. LPA observed that resident central storage logs were not documented correctly and had errors such as missing quantity of medication, incorrect dosage, incorrect expiration and fill dates, and not writing out the complete medication instructions. LPA also observed that medications were being prepoured in advance. LPA observed that 5PM medications were poured for a resident. Per Licensee, the medication had been poured that day around 11AM. LPA and Licensee discussed filling out the Centrally Storage Log (LIC622) accurately and live medication pouring expectations. Administrator's Certificate for Licensee, Silvana Daniel, (7036051740) was current with an expiration date of 03/21/2027.

LPA is requesting the following documents to update facility file:

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

Documents to be submitted to Community Care Licensing by 04/24/2026.

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 Licensee. Signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/24/2026 04:51 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 03/24/2026 at 03:42 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.625(b)(1)

Other Provisions

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, Licensee did not comply with the section cited above. LPA observed 1 of 2 staff files did not have proof of their 40 hours of traning prior to working with residents as required by the Health and Safety Code.This poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 03/25/2026
	Plan of Correction
1 2 3 4	Licensee to submit self-certification that proof of completed training will be completed for Staff Member 2 (S2) by POC due date of 03/25/2026. Licensee to provide proof of completed training for S2 by Friday, 04/03/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:

	Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/24/2026 04:51 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 03/24/2026 at 03:42 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(d)(1)

Storage Space and Access

(d) Residents may have access to items specified in subsection (c) for personal use unless there is documentation as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access. (1) The licensee shall implement reasonable interventions in order to ensure that access to the items specified in subsection (c) does not pose a hazard to other residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, Licensee did not comply with the section cited above. Laundry detergent and other cleaning products were observed to be assessible to residents in care during visit and were not properly locked in the cleaning cabinet. This poses an potential health/ safety/personal rights risk to persons in care.
	POC Due Date: 04/03/2026
	Plan of Correction
1 2 3 4	Licensee to provide proof of in-service training regarding items that could be hazardous or present a risk to residents. Proof of training to be submitted to Community Care Licensing (CCL) by POC due date of 04/03/2026.

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 record review, Licensee did not comply with the section cited above. 1 of 2 staff members did not have a health screening on file. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2026
	Plan of Correction
1 2 3 4	Licensee to submit proof of Staff Member 1's health screening to CCL by POC Due Date of 04/03/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:

	Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/24/2026 04:51 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 03/24/2026 at 03:42 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(a)

General Food Service Requirements

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made, Licensee did not comply with the section cited above. LPA observed instances of unlabeled and/or expired foods in facility’s fridge. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2026
	Plan of Correction
1 2 3 4	Licensee to conduct in-service training for staff members reviewing proper food labeling and storage. Training to include the following: Date, Topic, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date 04/03/2026.

Type B

Section Cited

CCR

87465(h)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made, Licensee did not comply with the section cited above and did not ensure that resident medications were centrally stored and recorded on the LIC622 as required. Log showed errors with missing quantity of medication, incorrect dosage, incorrect expiration and fill dates, and not writing out the complete medication instructions. This is a potential health and safety rights risk to residents in care.
	POC Due Date: 04/03/2026
	Plan of Correction
1 2 3 4	Licensee to submit self certification that proof of correctly documented LIC622 (Centrally Stored Log) will be done. Self-certification to be submitted by 04/03/2026. Proof of central stored log for the next shipment of medications (April 2026) for 3 of 7 residents to be submitted by 04/17/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:

	Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026

LIC809 (FAS) - (06/04)

Page: 5 of 8

Document Has Been Signed on 03/24/2026 04:51 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 03/24/2026 at 03:42 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, Licensee did not comply with the section cited above. 1 of 4 residents were found to not have an updated Appraisal as required. Resident's last appraisal was conducted in 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2026
	Plan of Correction
1 2 3 4	Licensee to submit proof of updated resident appraisal to CCL by POC due date of 04/03/2026.

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.

	Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:

	Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026

LIC809 (FAS) - (06/04)

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