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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800968
Report Date: 03/05/2024
Date Signed: 03/05/2024 05:30:03 PM


Document Has Been Signed on 03/05/2024 05:30 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
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: 6DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Mary Garcia- AdministratorTIME COMPLETED:
05:23 PM
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Licensing Program Analyst (LPA) Alviso conducted a Required -1 Year visit, on 3/5/24 at approximately 2:20pm, and met with Administrator Assistant Patty Thompson. 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 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.

The LPA toured the facility with the Administrator.

LPA reviewed six resident files. All resident files were complete. The LPA started a review on staff annual training.

This annual will be completed at a later date.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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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