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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801754
Report Date: 10/19/2022
Date Signed: 10/19/2022 01:59:54 PM


Document Has Been Signed on 10/19/2022 01:59 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:WHITE ROSE MANORFACILITY NUMBER:
496801754
ADMINISTRATOR:REMOLLO-SANTOS, GEORGIANAFACILITY TYPE:
740
ADDRESS:313 SHEILA COURTTELEPHONE:
(707) 776-0858
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 5DATE:
10/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:LIcensee Georgiana SantosTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection and met with via phone Licensee Georgina Remollo-Santos. The purpose of this case management inspection is to follow up on the submission of facilities mandatory Infection Control Plan.

LPA informed licensee they need to submit an infection control plan. LPA informed the facility that the licensee was granted a waiver under the Authority of Governor Newsom’s Executive Order N-11-22 issued on June 17, 2022, and the licensee agreed to submit the Infection Control Plan by December 19, 2022. LPA has given a facility a Technical Assistance at today’s visit (see LIC 9102TA).

No deficiencies cited during today’s inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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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