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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803979
Report Date: 05/18/2022
Date Signed: 05/18/2022 04:07:27 PM


Document Has Been Signed on 05/18/2022 04:07 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
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: 0DATE:
05/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Richard Froelich - AdministratorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced case management visit due to Regional Office in Santa Rosa learning that new license application for Aging in The Bay 3 # 286804070 at same location as Summer Rose Senior Living has had a fire clearance denied.

LPA arrived at facility and observed no residents' in care and facility under remodeling with individuals working at facility at this time. Facility was contacted on 5/13/2022 and staff Ganiel stated that administrator wasn’t available and would call Department back. On 5/17/2022 facility phone number was called and wasn’t receiving calls. Today on 5/18/2022, LPA spoke with Ganiel who stated that this location had been closed on 4/30/2022 and a new application had been submitted to the Application Bureau; staff also stated that administrator would be contacting me back. (picts on file)

During telephone call with administrator Richard Froelich, Department learned that 2 residents from this facility have been moved to new location due to losing lease at 1088 Donaldson Way, American Canyon; application has been submitted for change of location and pre-licensing is pending at this time, however; after receiving fire clearance for new location facility residents at this location were moved into new location at 120 Hawkesbury Way, Vallejo.

There are no deficiencies at this time.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
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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