496801754-1-17-2023-21-AS-SHAN-CN6QN6-20230117111836

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801754
Report Date: 01/17/2023
Date Signed: 01/17/2023 11:18:56 AM

Document Has Been Signed on 01/17/2023 11:18 AM - 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 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:	01/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Staff Evangeline Funtanilla and spoke w/ Licensee/Administrator Georgiana Santos		TIME COMPLETED:	11:20 AM

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	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 Evangeline. Georgiana R Santos Licensee/Administrator was contacted by facility staff on the telephone and wasn’t able to be present for this visit, LPA spoke with Licensee authorizing staff to sign documents. There is a total of six residents, all having dementia. Facility tour/inspection began at 8:40AM: LPA toured the facility with staff Evangeline; 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 107.7 degrees F and 112.4 degrees F in 2 out of 2 resident bathroom faucets which are within Title 22 acceptable regulation of 105 to 120 degrees F. 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 in a 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 although during tour LPA observed 2 unlocked kitchen drawers containing medications (see LIC809-D) including an unlocked cabinet containing a previous resident’s medication (see LIC 9102) for technical assistance. Facility has a 30-day supply of medication for residents. During tour LPA also observed front window to room not having required screen & back resident bathroom also not having a screen (see LIC9102) for technical assistance. 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: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

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: 01/17/2023

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
26
27
28
29
30
31
32

Infection Controle:

Facility has submitted a mitigation program plan and Infection Control Plan. Posters have been placed at facility. Facility has PPE supply stored in garage. Staff had all PPE training required on file as well have been N95 Fit Tested.

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 12/02/2022.

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

Administrator Certificate is for Georgiana R Santos #6019796740

All staff and residents have received COVID Boosters

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given.

LPA Hansen is requesting Licensee to update and submit the following documents by 02/03/2023 to SRRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 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: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5

Document Has Been Signed on 01/17/2023 11:18 AM - 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: WHITE ROSE MANOR	FACILITY NUMBER: 496801754
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

87465(h)(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation of medicaiton in 2 unlocked kitchen drawers, medications are accessible to residents in care. This is an immediate Health and Safety risk to residents in care.
	POC Due Date: 01/18/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit self certification that all medications are locked and inaccessable to residents in care. Licensee agrees to submit POC to CCL by 01/18/2023. And LIcensee agrees to submit document with title of training and signature sheet by staff and dated to CCL by POC 01/18/2023.

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: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5