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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800968
Report Date: 03/04/2025
Date Signed: 03/04/2025 03:30:19 PM

Document Has Been Signed on 03/04/2025 03:30 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:WILD ROSE CARE HOMEFACILITY NUMBER:
496800968
ADMINISTRATOR/
DIRECTOR:		GARCIA, MARYFACILITY TYPE:
740
ADDRESS:1921 QUAIL RUNTELEPHONE:
(707) 571-1910
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Mary Garcia-licensee/administratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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At approximately 12:30PM Licensing Program Analyst (LPAs) Stevenson and Alviso arrived to conducted an unannounced annual required inspection. LPAs observed a total of two(2) caregivers on duty. Mary Garcia, Licensee/Administrator arrived at approximately 12:40 PM
Facility has an approved dementia plan of operation. There is an approved hospice waiver for four (4) residents. Facility has a required infection control plan. Facility has a required emergency disaster plan. Fire clearance is approved for six (6) non-ambulatory, which includes one (1) bedridden, any resident room may be used for the bedridden clearance.

Mary Garcia has a current RCFE administrator certificate, #7003093740-expires 6/5/2025. Mary Garcia has a current RN license.

At approximately 1:00PM a tour of the facility was performed with licensee Mary Garcia and all knives, and toxins/cleaners were locked up and inaccessible to residents in care. All smoke alarms and the carbon monoxide detectors were checked by the local fire Department in August of 2024, and passed inspection, All smoke alarms and the carbon monoxide detector were tested and observed to be working properly. Fire extinguishers were observed to be charged and tagged as required and are scheduled to be re-inspected in May of 2025. All exits were clear and unobstructed. Hot water was checked at 114.4.F and 110.7F. which is within regulation. Facility was clean and orderly during the inspection. The facility was observed to be at a comfortable temperature and without odors. Food supply was observed to be sufficient, healthy appearing and of good variety.

LPAs reviewed medication records, records were complete; All medications were stored appropriately as required.
Continued on LIC809C
Kimberley MotaTELEPHONE: (707) 588-5051
Star StevensonTELEPHONE: 707-588-5081
DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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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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: WILD ROSE CARE HOME
FACILITY NUMBER: 496800968
VISIT DATE: 03/04/2025
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Continued from LIC809

At approximately 2:15PM, LPAs reviewed staff training records. Staff have required annual training, and have required first aid and CPR certifications. All staff have criminal record clearance as required.

At approximately 2:40PM LPAs reviewed client files and observed the files to have all required documentation. LPA's discussed with licensee to ensure that the appraisal and needs service plans are review with and signed by pertinent parties.

LPA is requesting the following documents be updated and submitted to CCL by 4/04/24.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of Current Liability Insurance
Resident Roster

No deficiencies cited in today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Star StevensonTELEPHONE: 707-588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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