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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804073
Report Date: 10/27/2023
Date Signed: 10/27/2023 04:19:46 PM


Document Has Been Signed on 10/27/2023 04:19 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:BERNARDINO, KRISTINEFACILITY TYPE:
740
ADDRESS:120 HAWKESBURY WAYTELEPHONE:
(707) 515-9099
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
10/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Myla Escalante, care staffTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a change of ownership inspection for applicant taking over this facility and met with care staff, Myla Grace Alcalde.

During today's inspection LPA found the front door and both sliding doors, with the auditory alarm not operational and facility provides care to residents with Dementia diagnoses. LPA also requested facility to remove extra garbage and furniture in the backyard on the side of the metal shed. LPA also requested facility to service both sliding doors so that they open easily.
In addition, LPA requested clarification regarding resident R1 with a pressure injury that is healing.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Report emailed to Administrator.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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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Document Has Been Signed on 10/27/2023 04:19 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2023
Section Cited
CCR
87705(j)

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87705(j) Care of Persons with Dementia(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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Facility to send in written statement they understand regulation and how they will insure they stay in compliance. facility to send in proof of staff training
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This requirement was not met as evidenced by: during todays inspection 3 out of 3 doors auditory alarms were not operational and facility has rewsidents with Dementia. This is an immediate risk to the health and safety of residents in care.
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POC due date 10/29/2023 attention LPA Araceli Canela

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
LIC809 (FAS) - (06/04)
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