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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801754
Report Date: 02/13/2023
Date Signed: 02/13/2023 11:59:03 AM


Document Has Been Signed on 02/13/2023 11:59 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 MANORFACILITY NUMBER:
496801754
ADMINISTRATOR:REMOLLO-SANTOS, GEORGIANAFACILITY TYPE:
740
ADDRESS:313 SHEILA COURTTELEPHONE:
(707) 776-0858
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 6DATE:
02/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Glenda Castle, designeeTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection and met with designee Glenda Castle. The purpose of this case management inspection is to follow up on Technical Advisories given at Annual Inspection on 1/17/2023.

During the annual inspection facility was given an LIC9102 TA for facility not disposing of medications for residents who are no longer in care. On today's inspection LPA observed facility not containing such medications and discussed with designee Glenda they were properly disposed of. During annual inspection LPA also gave facility a 2nd LIC9102 TA for not having window screens on 2 windows. Facility has not fixed as of yet. Designee informed handyman has yet to fix. LPA suggested to call a local hardware store for easy directions.

Facility was informed LPA will be back within 2 weeks to inspect.

There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023
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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