496803042-9-17-2024-21-AS-DALO-D97V8Z-20240917161333

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803042
Report Date: 09/17/2024
Date Signed: 09/17/2024 04:13:40 PM

Document Has Been Signed on 09/17/2024 04:13 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
SANTA ROSA RO, 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:	09/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Erika Molina-Administrator		TIME COMPLETED:	04:30 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 visit, at approximately 11:50am on 9/17/24, and met with Administrator Erika Molina. Facility has an approved dementia plan of operation. There is an approved hospice waiver for three (3) residents. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden. Facility has required smoke alarms, ten (10), which are also carbon monoxide detectors. Fire extinguishers, three (3) were serviced and tagged as required. LPA reviewed six (6) resident files; Resident files were complete. LPA reviewed five (5) staff files. All staff had required training; All staff had required first aid and CPR certifications. All staff had criminal record clearance s required. The facility was at a comfortable temperature. Hot water was checked at 110.5 degrees Fahrenheit. All exits were free and clear of obstruction. All exit doors had auditory alarms, and they were working properly. Food supply was sufficient. LPA observed sufficient supplies of hygiene products, paper products, disinfectants/cleaners, linens, and personal protective equipment (PPE). All bathrooms had grab bars, and mats/non-slip flooring in showers for resident use. Facility had sufficient lighting in all resident rooms, hallways, bathrooms, and common areas. Medications were locked up and inaccessible to residents in care. All disinfectants/cleaners were locked up and inaccessible to residents in care. Continued on LIC809C..

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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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Document Has Been Signed on 09/17/2024 04:13 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
SANTA ROSA RO, 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: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Per LPA's file review, there were no emergency drills documented for 2024, facility failed to comply with H&S Code;; Administrator was not able to provide the proof of completing the drills, the drills are done quarterl on each shift for the year, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/17/2024
	Plan of Correction
1 2 3 4	Administrator to ensure that the required emergency drills are completed and documented; Ensure the emergency drills are completed for every shift. Two drills are past due, and one is due this September 2024. Submit plan of future compliance and proof of completed emergency drills. POC due 10/17/24.

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) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WILD ROSE CARE HOME AT HARDIES LANE	FACILITY NUMBER: 496803042
	VISIT DATE: 09/17/2024

NARRATIVE

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LPA is requesting the following documents be updated and submitted by 10/17/24.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (must complete the form- include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate.

The following deficiency was observed during facility file reviews:

Per LPA's file review, there were no emergency drills documented for 2024, facility failed to comply with H&S Code requirements. Administrator was not able to provide the proof of completing the drills, the drills are done quarterly, in the year. This deficiency will be cited, 1569.695(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill, see LIC809D.

Deficiencies 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 with Administrator Erika Molina.
Appeal Rights provided to the Administrator.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

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