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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804073
Report Date: 11/06/2023
Date Signed: 11/06/2023 06:28:19 PM


Document Has Been Signed on 11/06/2023 06:28 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:
11/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:38 PM
MET WITH:Kristine BernardinoTIME COMPLETED:
05:14 PM
NARRATIVE
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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. Administrator, Kristine Bernardino arrived a few minutes later.

During today's inspection LPA found a small bottle of lysol along with a hand held razor, bottle of super glue, neosporin, can spray that contains lidocaine, all accessible in master bedroom bathroom. Facility explained the items belong to staff S1. LPA went over items being accessible to residents and once again explained the master bedroom bathroom may only be used by the two residents who occupy that bedroom, R1 and R2. LPA requested removal of all accessible toxins and items belonging to staff S1 who should not be stored in the residents bedroom.

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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
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 11/06/2023 06:28 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: 11/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2023
Section Cited
CCR
87705(f)(2)

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87705(f)(2)Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Facility to send in written plan they understand regulation and how it will be followed. Facility removed items that should not be accessible and will conduct and send proof of staff training.
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This requirement was not met, as evidenced by: During today's visit LPA found , Lysol bottle, shaving razor, neosporin oitnment, crazy glue in master resdient bathroom, not locked. This is an immediate risk to Health & Safety of residents in care.
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POC due date 11/7/2023 to 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: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
LIC809 (FAS) - (06/04)
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