496801754-3-11-2025-21-AS-SHAN-DENTXZ-20250311150758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801754
Report Date: 03/11/2025
Date Signed: 03/11/2025 03:55:00 PM

Document Has Been Signed on 03/11/2025 03:55 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 MANOR		FACILITY NUMBER:	496801754
ADMINISTRATOR/ DIRECTOR:	REMOLLO-SANTOS, GEORGIANA		FACILITY TYPE:	740
ADDRESS:	313 SHEILA COURT		TELEPHONE:	(707) 776-0858
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	03/11/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Glenda Castle, Designee		TIME VISIT/ INSPECTION COMPLETED:	03:20 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	License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual visit of the facility. LPA was welcomed by staff Glenda Castle. 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. RCFE is a single story 6 bedroom, 3 bathroom with fire clearance for six Non-Ambulatory of which 3 may be bedridden in rooms 2, 3, & 4 and Hospice Waiver for 3. There is currently a total of 6 residents, 4 with diagnosis of dementia, one resident on hospice. Facility tour/inspection began at 1:10 PM: LPA toured the facility with staff Glenda; 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 time of visit. Fire Extinguisher was found to be last charged on 1/24/2025 at the time of the visit. Smoke/carbon monoxide detectors are hard wired throughout facility, last inspected by Fire Dept. 2/25/2025. Hot water temperature measured 105 degrees F and 107.2 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. Sharps/knives are stored in locked container on kitchen counter, 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, although at this time there is a shower wheelchair most residents are currently sitting in while being bathed in the shower. All bedrooms have lighting & appropriate furnishings. Continue on LIC809-C

Bethany Moellers	TELEPHONE: (707) 588-5026
Shannan Hansen	TELEPHONE: 707-588-5026
	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

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: 03/11/2025

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Continued from LIC809
File Review began at 2:00 PM:
A review of five resident & four staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files and learned 5 out of 5 resident resident records reviewed have updated re-appraisals/needs & care plans and 5 out of 5 residents have current physician’s reports. All files are current.

LPA reviewed a sample of staff records and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements for 2024 are on file. LPA was presented with proof of CPR & 1^st Aid certification for staff that files were reviewed.

Medications were centrally stored in locked cabinet in the facility office room area. Facility has a 30-day supply of medication for residents.

The Medications of 2 out of 2 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

Administrator Certificate for Administrator, Georgiano Santos 7005931740 expires 8/25/2026. Last Disaster Drill was conducted on 2/6/2025. Disaster drills are to be conducted quarterly and in different shifts.

No Citations given at today's inspection Exit interview conducted with Designee.

LPA Hansen is requesting facility to submit the following documents to CCL by 3/25/2025:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Resident’s
Copy of Current Administrators Certificate
Copy of Certificate 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: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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