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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800968
Report Date: 04/06/2022
Date Signed: 04/06/2022 02:53:18 PM


Document Has Been Signed on 04/06/2022 02:53 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:WILD ROSE CARE HOMEFACILITY NUMBER:
496800968
ADMINISTRATOR:GARCIA, MARYFACILITY TYPE:
740
ADDRESS:1921 QUAIL RUNTELEPHONE:
(707) 571-1910
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 5DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Erika Molina-AdministratorTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Dina Alviso conducted 1 year required inspection and met with Administrator Erika Molina, who came from Wild Rose Hardies Lane to meet with the LPA. . Licensee/Administrator, Mary Garcia arrived to the facility not long after, and continued the inspection with the LPA. The inspection is focused on the Infection Control procedures and practices of this facility.

All visitors, essential visitors, and staff are screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents' are screened on each shift (3 shifts) a day, and all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets, and the laundry room which contains cleaners and toxins was locked and inaccessible to residents in care. There was a sufficient supply of hygiene products, and paper products for use as needed. Medications were stored locked making them inaccessible to residents. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE) for staff use, and for residents as needed and/or wanted. Administrator and the Licensee had a mask on during the LPA's inspection. Facility has an approved dementia plan of operation. There is an approved hospice waiver for four(4) residents. Mitigation plan was received and reviewed by the Department. Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden, any resident room may be used for the bedridden (1)clearance.
There were five (5) residents in care at the facility during this inspection. One(1) resident on hospice care services.
No deficiencies during today's inspection.
No citations issued.
Exit interview conducted with the Licensee.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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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