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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804074
Report Date: 09/28/2023
Date Signed: 09/28/2023 12:55:36 PM

Document Has Been Signed on 09/28/2023 12:55 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ROSE RENEE RESIDENTIAL CARE FACILITYFACILITY NUMBER:
486804074
ADMINISTRATOR:FRASIER, FELICIAFACILITY TYPE:
735
ADDRESS:1220 SERENO DRTELEPHONE:
(707) 980-6830
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 4CENSUS: 1DATE:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Anthony Frasier, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Carol Fowler is conducting an Required-1 Year inspection, on 9/28/2023 at approximately 09:00am, and met with Anthony Frasier, Administrator. Felicia Frasier, Administrator arrived approximately 10:15am LPA observed two on duty during the inspection.

Currently one (1) client in care. Facility has an approved fire clearance four (4) ambulatory clients. All client rooms are private. The facility has required emergency disaster plan.

Facility scheduled evacuation fire drill will be 09/30/2023, including staff & client. Client, 1 out of 1, special diets regarding food are followed per staff interviews, and per LPA's observations during the inspection.

The LPA reviewed two(2) staff files. Administrator certificate for Anthony Frasier is current-#6049162735, expires 7/8/2024. All staff have required criminal record clearance. All staff have required training. The LPA reviewed one (1) client files. Client files were complete. P&I clients monies were maintained as required, and not mixed with facility funds/any other funds.

The LPA toured the facility with the Administrators. All exits were unobstructed. The facility fire extinguisher was serviced and tagged as required expires 04/17/2023. Facility had four (4) smoke alarms, and all were working properly when checked during the inspection. Facility had one (1) carbon monoxide detector that were working properly when checked during the inspection. Facility had a first aid kit stored in the hallway and one locked in storage, it did have a required first aid booklet. The facility had a first aid kit, and first aid booklet, in the client transportation vehicle. The facility had a sufficient supply of perishable and nonperishable food.

Continue on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ROSE RENEE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 486804074
VISIT DATE: 09/28/2023
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The facility had food, water, and emergency supplies to meet the 72 hour shelter in place requirement. The facility had a sufficient supply of personal protective equipment(PPE) for use as needed. The facility had a sufficient supply of hygiene supplies, cleaning supplies, and paper products for use as needed. The LPA observed the facility to be clean and orderly during the visit. The LPA observed that resident rooms, common areas, hallways, and bathrooms had sufficient lighting for clients in care. Clients rooms had required accommodations per regulations. Facility had all medications locked up and inaccessible to clients in care as required. Facility had all cleaners/toxins locked up and inaccessible to clients in care as required.

LPA is requesting the following forms be updated and submitted to CCL by 10/11/23:

· LIC 500 -Personnel Report
· LIC 610D - Disaster Plan
· LIC 308 - Designation of Responsibility
· LIC 308 - Copy of Administrator Certificate
· Affidavit Regarding Client Cash Resources
· Copy of Surety Bond in Required Amount
· Infection Control Plan If updated
  • Control of property

No deficiencies cited at todays inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
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