496801754-2-10-2022-21-AS-SHAN-CBHVAU-20220210151632

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801754
Report Date: 02/10/2022
Date Signed: 02/10/2022 03:17:16 PM

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:	WHITE ROSE MANOR		FACILITY NUMBER:	496801754
ADMINISTRATOR:	REMOLLO-SANTOS, GEORGIANA		FACILITY TYPE:	740
ADDRESS:	313 SHEILA COURT		TELEPHONE:	(707) 776-0858
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	6	CENSUS: 6	DATE:	02/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Glenda Castle - Designee		TIME COMPLETED:	02:30 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	On 02/10/2022 at 12:15 PM License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required 1-year infection control inspection visit of the facility. LPA was welcomed by staff Glenda Castle, designee. Georgiana R Santos Licensee/Administrator was contacted by facility staff on the telephone and wasn’t able to be present for this visit. There is a total of six residents with one in the hospital, four are dementia residents. There are two residents currently on Hospice. Facility tour/inspection began at 12:30 PM: LPA toured the facility with Glenda Castle; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices that were working properly during the visit. Fire Extinguisher was found to be last charged on 1/24/2022 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured 120 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in resident’s bathroom faucet while touring facility. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in the garage and locked laundry cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Medications are kept and centrally stored in locked office cabinet. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

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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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: WHITE ROSE MANOR	FACILITY NUMBER: 496801754
	VISIT DATE: 02/10/2022

NARRATIVE

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Infection Controle:

Facility has submitted a mitigation program plan that has been approved, on 7/23/2021. All staff and visitors check in and log temperatures and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. Facility has PPE supply stored in office in bins. Facility has a 30-day supply of medication for residents. Staff had all PPE training required on file as well have been N95 Fit Tested at Concentra. All staff and residents have been fully vaccinated and boostered and all staff work exclusively at this facility.

In addition, facility has designated areas for visitors in bedrooms (they are all individual) and other areas which are being allowed for visits. Residents also have available zoom, facetime, and telephone calls when contacting with family members and others and assistance if needed. Disaster Drills are conducted quarterly with the last being 12/2021.

LPA reviewed Licensing Information System (LIS) with designee who stated that is correct and updated at this time; no need to change any of the information. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA discussed new PIN 22-05 & 22-07.

LPA was presented with proof of CPR & 1^st Aid certification for staff.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 3/3/2022 to RPRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

LIC809 (FAS) - (06/04)

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