486804073-5-19-2022-21-AS-CFGS-CEJV5Q-20220518160820

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804073
Report Date: 05/18/2022
Date Signed: 05/19/2022 10:49:54 AM

Document Has Been Signed on 05/19/2022 10:49 AM - 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 LLC		FACILITY NUMBER:	486804073
ADMINISTRATOR:	FROELICH, RICHARD		FACILITY TYPE:	740
ADDRESS:	120 HAWKESBURY WAY		TELEPHONE:	(707) 515-9099
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 2	DATE:	05/18/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Richard Froelich & Gainel Malybaeva - Licensees		TIME COMPLETED:	04:08 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) Fernandes-Goes conducted a pre-licensing inspection and met with Licensee & Administrator Richard Froelich and Gainel Malybaerva. Fire clearance has been approved for 6 non-ambulatory residents by the County Fire Department. LPA will conduct COMP III orientation in the follow up visit that will need to be conducted for this facility. There is a total of 2 residents with non under Hospice care. Facility is a one-floor facility which includes kitchen, laundry room, living room area, bathrooms, office area, dining room, resident's bedrooms, and bathrooms. LPA toured the facility on 5/18/2022 with Licensee/Administrator Richard F. and Gainel M who arrived during the visit; facility was found to be at a comfortable temperature with all exits free from obstruction. There is outdoor space for activities. Fire Extinguisher was found to be last charged on 5/18/2020 – there is no tag, however; fire clearance was conducted on 4/28/2022 and regulator is on green. LPA tested facility smoke detectors which are all connected as required by County Fire Department, alarms went off however; didn’t stop. Licensee Richard F had to disconnect them during this visit because they wouldn’t turn it off. Carbon monoxide detector was found to be operational. Hot water temperature measured 136.4 degrees F and 140.1 degrees F falling out Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathroom faucets. The facility has special care plan of operation and programming for residents with dementia. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. LPA observed closets without doors in residents bedroom #C and #B; sliding screen door in room #A is not properly opening; window screen in family room has an open the size of a hand palm. Outside can use some attention. Food stored in the kitchen refrigerator were properly stored as per regulations. Food is available for residents any time of the day. LPA observed several canned foods stored in kitchen cabinets expired at the time of the visit. Licensee Richard discarded expired food during this visit. There are outside activities available for residents and no posted activities due to COVID. Continued LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LLC	FACILITY NUMBER: 486804073
	VISIT DATE: 05/18/2022

NARRATIVE

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Facility is conducting individual activities at this time. Toxins are stored in a locked closet in facility hallway and under kitchen sink. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with individual towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Closets in bedroom A & B need doors and/or curtains to cover opened. Mattress pads are available for residents. Licensee Richard F. stated that they are only planning to have only 4 residents. LPA also observed that there is not enough space for 2 residents' with required furniture in bedrooms A & B.

Facility plans on having several different activities available for residents as desired and an activity calendar posted by the dining room/kitchen as well. Resident's & Personnel records, medication, first aid supplies, and toxins will be locked in hallway closets. Postings noted to be current and in compliance with guidelines with the following postings missing: Hand washing in bedroom #A bathroom, masks required, Non-discrimination, Theft & Loss; Residents Council Rights, “Let us Know” – PUB 475 for complaint hotline.
Staff at facility during this visit S1 wasn’t fingerprinted cleared and/or associated to the facility and in addition file had no required training, LIC 501 – employee application, and/or LIC 508 – criminal record statement. Licensee and S1 stated that staff was cleared under HSS. S1 left during this visit to get fingerprinted and licensee will be working until able to have qualified staffing.

LPA reviewed during this visit incident report that was submitted on 4/27/2022 in which resident R1 was administering own injections and glucose tests. Facility licensees understand that residents can only conduct their own injections and glucose tests if authorized by physician, otherwise only a skill professional is allowed to administer any injections or testing as per Title 22 Regulations # 87628.

In addition, Department learned that this facility was located at 1088 Donaldson Way, American Canyon and submitted application requesting change of location due to losing lease to property. On 4/30/2022 facility Summer Rose Senior Living # 286803979 at 1088 Donaldson Way, American Canyon closed, and 2 residents were moved to new location after receiving fire clearance (120 Hawkesbury Way, Vallejo).

Continued LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 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

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SUMMER ROSE SENIOR LIVING LLC	FACILITY NUMBER: 486804073
	VISIT DATE: 05/18/2022

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Community Care Licensing has requested the following items be corrected prior to licensure:

- Licensee adjusted the hot water temperature during this visit. Department is requesting a 7 day log of hot water temperature.
- Proof of smoke detectors being inspected and working properly.
- Door or curtain for closet doors in residents' bedrooms # B & #C
- Copy of Liability Insurance
- Following postings missing placed in facility: Hand washing in bedroom #A bathroom, masks required, Non-discrimination, Theft & Loss; Residents Council Rights, “Let us Know” – PUB 475 for complaint hotline.

Department will be conducting another visit to verify items listed above and conduct COMP III.

There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 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

LIC809 (FAS) - (06/04)

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