496803042-8-4-2022-21-AS-DALO-CGZ22J-20220804170050

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803042
Report Date: 08/04/2022
Date Signed: 08/04/2022 05:00:56 PM

Document Has Been Signed on 08/04/2022 05:00 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:	WILD ROSE CARE HOME AT HARDIES LANE		FACILITY NUMBER:	496803042
ADMINISTRATOR:	MOLINA, ERIKA		FACILITY TYPE:	740
ADDRESS:	2564 HARDIES LANE		TELEPHONE:	(707) 526-2434
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 6	DATE:	08/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Erika Molina-Administrator		TIME COMPLETED:	05:12 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	Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a Required 1 Year inspection, and met with Administrator Erika Molina. The inspection is focused on the Infection Control procedures and practices of this facility. All visitors, and staff are screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents are screened daily, and observed for any changes, all information is logged. LPA was screened by staff as required. Facility has an approved dementia plan of operation. There is an approved hospice waiver for three (3) residents. Facility recently submitted the Infection Control Plan as required by the department. Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden. Fire extinguishers, three(3) were charged, tagged, and serviced as required. All exit alarms were on exit doors and working properly. There were six (6) residents in care at the facility during this inspection. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents in care. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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: WILD ROSE CARE HOME AT HARDIES LANE	FACILITY NUMBER: 496803042
	VISIT DATE: 08/04/2022

NARRATIVE

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All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment (PPE). LPA observed all staff to be wearing masks as required.
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LPA observed that the facility's fire extinguishers had service tags that had expired, two(2) expired on 6/1/2022, and one (1) expired on 6/18/2022. Administrator stated that the service company had come out, and serviced the fire sprinklers not the fire extinguishers as thought. They have an appointment set up for 8/25/2022 for the extinguishers to be serviced.. This deficiency is being cited today, 87203 Fire Safety, see LIC809D.

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 to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/04/2022 05:00 PM - 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: WILD ROSE CARE HOME AT HARDIES LANE	FACILITY NUMBER: 496803042
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, , the licensee did not comply with the section cited above in [3] out of [3] [ fire extinguishers , which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2022
	Plan of Correction
1 2 3 4	Licensee to ensure that all fire extinguishers are annually serviced as required. Administrator stated that she will be purchasing new fire extinguishers for the facility tomorrow, and keeping the service date for the original fire extinguishers as scheduled. Licensee will sibmit proof of purchased extinguishers, submit pictures. Submit plan on maintaining compliance with this regulation. POC due 8/5/2022.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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