496800968-4-11-2023-21-AS-DALO-CQSVME-20230411163324

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800968
Report Date: 04/11/2023
Date Signed: 04/11/2023 04:33:35 PM

Document Has Been Signed on 04/11/2023 04:33 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 HOME		FACILITY NUMBER:	496800968
ADMINISTRATOR:	GARCIA, MARY		FACILITY TYPE:	740
ADDRESS:	1921 QUAIL RUN		TELEPHONE:	(707) 571-1910
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 5	DATE:	04/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Claudia Maciel-Caregiver		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Alviso conducted a Required-1 Year visit, on 4/11/23 at approximately 9:35am, and met with Caregiver Claudia Maciel. LPA observed a total of two(2) caregivers on duty. Mary Garcia, Licensee/Administrator was contacted notifying her of the LPA's arrival to the facility. Garcia arrived within 30 minutes of being notified. Facility has an approved dementia plan of operation. There is an approved hospice waiver for four(4) residents. Facility submitted to the Department the required infection control plan. 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 are five(5) residents in care. LPA reviewed five(5) of five(5) resident files; All resident files were found to be complete. All three(3) staff have criminal record clearance and are associated as required. LPA reviewed three(3) of three(3) staff files. Staff S1 is a Registered Nurse, license is maintained and active. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. All eleven(11) smoke alarms, which are hard wired, were working properly during the inspection. Three fire extinguishers were serviced and tagged as required. Medications were stored and locked making them inaccessible to residents. All toxins and cleaners were stored in locked cabinets, and inaccessible to residents in care. There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed. Facility has a sufficient supply of personal protective equipment(PPE) for staff use as needed. Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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 04/11/2023 04:33 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: WILD ROSE CARE HOME	FACILITY NUMBER: 496800968
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.69(a)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record reviews, two(2) out of two(2) file reviews, the licensee did not comply with the section cited above in 2 of 2 staff persons which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/12/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that staff S2 & S3, obatain required annual medication training. Licensee to submit plan of correction in staff getting the training, and submitting proof of staff's training being completed. POC due 4/12/23. Proof of training on S2 & S3 to be submitted by 4/18.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/11/2023 04:33 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: WILD ROSE CARE HOME	FACILITY NUMBER: 496800968
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record reviews, the licensee did not comply with the section cited above in two(2) out of two(2) persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that staff S2 & S3 obtain required annual training hours, total of 20 per H&S Code. Submit proof of staff having completed required training hours. POC due 4/28/23.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and iterview with staff 1, the licensee did not comply with the section cited above in ensuring quarterly drills are conducted, last was held on 8/6/22, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Licensee to enure that the quaterly drills are held as required per H&S Code. Submit plan on maintaining compliance with this health and sfety code, and submit proof of having held a drill as required-quarterly. POC due 4/28/23.

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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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: WILD ROSE CARE HOME	FACILITY NUMBER: 496800968
	VISIT DATE: 04/11/2023

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Per LPA's file review, two(2) out of two(2) staff lack proof of annual training hours having been completed per regulations/H&S Code. This will be cited, Staff training; legislative findings; contents, Personal Care Services-H&S Code 1569.625(b)(2) Required 20 hours annually, consists of eight(8) hours dementia care, four(4) hours of postural supports, restricted conditions, and hospice care, and eight(8) hours, licensees discretion, of other staff training completed-total of twenty(20) hours annually. See LIC809D.

Per LPA's file review, two(2) out of two(2) staff(S2 & S3) lacked required annual medication training hours. This will be cited, Employees assisting residents with self-administration of medication; training requirement-H&S Code 1569.69(a) All staff are required to obtain medication training to assist residents with medications. Annual medication training is required by all staff assisting residents with medications. S2 & S3 lacked annual medication training, see LIC809D.

Per file review and interview, the facility's last drill was conducted on 8/6/2022, and per Licensee there has not been a drill held quarterly since 8/6/22. This will be cited, Emergency Plans H&S Code 1569.695(c)- A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios, see LIC809D.

LPA provided a technical advisory regarding Personnel Requirements -General 87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. Two staff have a first aid refresher course , certificates don't have specific information to if it is certification of first aid and when it expires. Training is completed by Relias. Licensee to follow-up and update the records as needed/required with first aid certification.

LPA requested the following documents to be sent no later than 4/28/23:
LIC 500- Personnel Report, LIC 308- Designation of Responsibility, Updated Emergency Disaster Plan (LIC 610E), Most up-to-date Liability insurance, Register of residents.

The following deficiencies were observed (See LIC 809D pages) and cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Failure to correct the deficiency(s) and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and a copy of this report along with appeal rights were given to Facility Licensee/Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

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