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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804073
Report Date: 05/16/2023
Date Signed: 05/16/2023 02:43:02 PM

Document Has Been Signed on 05/16/2023 02:43 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:
486804073
ADMINISTRATOR:FROELICH, RICHARDFACILITY TYPE:
740
ADDRESS:120 HAWKESBURY WAYTELEPHONE:
(707) 515-9099
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 6DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Christine BernardinoTIME COMPLETED:
02:16 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, new Administrator, Christine Bernardino. LPA requested facility to submit the required paperwork to Community Care Licensing (CCL) to change the administrator to be Christine Bernardino. There are currently 6 residents living in this facility. This facility is licensed for 6 non-ambulatory residents, with no approval for bedridden and there is no Hospice waiver in place. Facility may not accept Hospice residents until they have requested and received approval to accept residents who are on Hospice.

LPA toured facility and grounds and observed facility was found to be clean at a comfortable temperature with all exits free from obstruction. Resident rooms have the required furnishings and linens. Medications are stored locked in a
locked cabinet in the hallway closet. Extra hygiene products and linens were available. 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 5/16/2022 with care staff Elle Obias, Administrator, Christine was called and arrived later. There is outdoor space for activities, but the fabric cover to the gazebo is partially hanging and will need to be put back in place to provide shade. Fire Extinguisher was found to be charged but did not have the required tag for proof of when it was serviced. Carbon monoxide detector was found to be operational. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Food is available for residents during the day. LPA observed there is a latch on the refrigerator that will need to be removed immediately as the facility does not have an approved exception from CCL to lock the refrigerator at night.

Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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: 05/16/2023
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LPA requested clarification and records regarding 2 residents who may have pressure injuries. Medications were observed accessible in 2 resident rooms, one with tylenol bottle in bathroom for R1/R2 and a small container with medication pills and an inhaler in resident R3s bedroom. Cleaning supplies were observed not locked in kitchen, laundry area and guest bathroom which were accessible to residents. LPA observed window screen in family room has an opening/hole, the size of a two hand palms and needs to be replaced. There was no screen in the dining room sliding door and one will need to added. Outside can use some attention, there were broken ceramic pot pieces, several boxes on the side yard and overgrowing plants, all will need to be corrected and removed. LPA requested facility to service side yard gate as the weather has affected it and gate needs to open easily.

Licensee/Administrator to submit paperwork to change and correct the Administrator to Christine XX by 5/22/2023


Licensee/Administrator to submit the current following documents by 6/15/2023:

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Infection Control Plan of Operation (If changes)
· Proof of Liability Insurance
· Copy of current Lease Agreement

LPA will return to review additional resident and staff files, go over medication requirements, complete inspection and issue citations observed and/or noted during this visit.

No citation issued at this time.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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