286803979-8-19-2021-21-AS-AELT-C62SGY-20210819135241

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286803979
Report Date: 08/19/2021
Date Signed: 08/19/2021 01:53:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	SUMMER ROSE SENIOR LIVING, LLC		FACILITY NUMBER:	286803979
ADMINISTRATOR:	FROELICH, RICHARD W.		FACILITY TYPE:	740
ADDRESS:	1088 DONALDSON WAY		TELEPHONE:	(707) 515-9099
CITY:	AMERICAN CANYON	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 6	DATE:	08/19/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Elena Efe/Richard Froelich		TIME COMPLETED:	01:00 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) Angela Elliott conducted an unannounced Pre-Licensing Inspection. This pre-licensing inspection is being conducted due to a change of ownership. LPA was greeted by Licensee Elena Efe. Richard Froelich, applicant arrived later. The facility is had 3 resident bedrooms and 1 room designated for caregivers. There are 2 bathrooms. No residents are on Hospice. LPA toured the entire premise which was found to be clean and orderly. Fire extinguisher last inspected 6/16/2021. Smoke detectors tested and found to be in working order. Carbon monoxide detector was located in the resident hallway and found to be in working order. Medications are in locked cabinets . Toxins and cleaning supplies are secured in a locked cabinet in the garage. Personal Protective Equipment and Emergency supplies are also kept in the garage. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for current census. There is a closet located in garage that holds extra linens and towels. Beds were made with appropriate linens. Required furniture was not in residents bedrooms. LPA observed hott water temperature measured between 110.2 and 115.7 degrees F and was within regulation between 105 degrees F and 120 degrees F. There was an ample supply of dishes and cooking supplies. Required postings such as Complaint poster, Rights to resident councils, client's rights are posted in the facility. Resident and staff records, all contained required documentation, except a current Medical Assessment for R1. LPA observed R1 was disposing of sharps in a plastic coffee creamer container. Licensee indicated R1 had a sharps disposal container in their closet but wasn't using it. Sharps disposal container was obtained and will be used moving forward. Report continued on LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SUMMER ROSE SENIOR LIVING, LLC	FACILITY NUMBER: 286803979
	VISIT DATE: 08/19/2021

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A fire clearance for this facility has been granted for 0 bedridden and 6 non-ambulatory clients. LPA requested updated Medical Assessment for R1 8/27/2021. LPA requested copies of pictures of resident bedrooms with required furnishings by 8/27/2021. LPA requested copy of Mitigation Plan by COB 8/27/2021.

Component III orientation was conducted with the Licensee and Applicant.

The pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager.

This report will be forwarded to the Centralized Application Unit.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC809 (FAS) - (06/04)

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