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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803979
Report Date: 01/28/2022
Date Signed: 01/28/2022 11:26:02 AM

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:SUMMER ROSE SENIOR LIVING, LLCFACILITY NUMBER:
286803979
ADMINISTRATOR:FROELICH, RICHARD W.FACILITY TYPE:
740
ADDRESS:1088 DONALDSON WAYTELEPHONE:
(707) 515-9099
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY:6CENSUS: 2DATE:
01/28/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Richard Froelich (Licensee)TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced post-licensing inspection and met with Licensee, Richard Froelich. LPA conducted risk assessment call prior to make the visit.

During today’s visit LPA/Licensee observed the following items: COVID-19 postings and screening station at entrance. LPA was screened prior to entering. Facility submitted Mitigation Plan in January 2022 and it's currently under review by CCL. All exits were unobstructed and auditory devices in exit doors, observed operational. Fire Extinguisher charged on 6/6/21, hardwired combination smoke and carbon monoxide detectors, which were tested and observed to be operational. Supply of linens, paper products, and hygiene supplies available. Required furnishings in all 3 resident bedrooms and 1 room for caregivers, grab bars and non-slip mats in 2 of 2 bathrooms. Water temperature was tested & within regulation of 105 to 120 degrees F. Medications are in locked cabinets. Toxins, cleaning supplies and PPE are secured in a locked cabinet in the garage. Food supplies were within regulation at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food.

The Administrator Certificate expires 01/26/2022 and it is in pending approval status. Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Emergency Disaster Plan, Client personal rights and visitor policy) Disaster drill conducted on November 2021. Facility records reviewed, staff have CPR, 1st Aid certifications and vaccination records which includes 100% vaccination rate for residents and staff. LPA will provide Everbridge information for Licensee to subscribe.


No deficiencies cited during today's inspection
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
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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