496803042-8-8-2023-21-AS-DALO-CUHVMV-20230808163410

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803042
Report Date: 08/08/2023
Date Signed: 08/08/2023 04:34:18 PM

Document Has Been Signed on 08/08/2023 04:34 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: 5	DATE:	08/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Erika Molina-Administrator		TIME COMPLETED:	04:40 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 Analysts(LPAs) Alviso and Rummonds arrived unannounced to conduct a Required -1 Year visit, at approximately 9:30am on 8/8/23, 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. All smoke alarms, 10, which are also carbon monoxide detectors, were working properly during the inspection. LPA observed a screening area by the front door to use as needed. LPAs' toured the facility. All exits were clear and unobstructed. All postings were up and visible to all as required. Fire extinguishers(3) were serviced and tagged as required- expires 6/11/24. Hot water was checked at 106.8F. Facility has a sufficient supply of personal protective equipment(PPE) for use as needed. Toxins are stored in locked cabinets, and the laundry room which contains cleaners and toxins was locked and inaccessible to residents in care. There was a sufficient supply of hygiene products, and paper products for use as needed. Medications were stored locked making them inaccessible to residents. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. LPA reviewed five(5) resident files. All files were complete. LPA reviewed five(5) staff files. All staff had criminal record clearance as required. 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: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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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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: 08/08/2023

NARRATIVE

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LPA is requesting the following documents be updated and submitted by 9/8/23:
LIC308 - Designation of Administrator Responsibility
LIC610E-Emergency Disaster Plan (ensure to provide all information in all boxes as required)
Copy of LIC400 Handling of Client Cash Resources
Copy of Current Liability Insurance

Per LPA's record reviews, three(3) out of five(5) staff lacked proof of initial/ annual training, records were unclear regarding hours completed. This deficiency will be cited,87411( c) Personnel Requirements – General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69, see LIC809D.

Per LPA's record reviews, one(1) out of five(5) staff lacked current first aid certification as required. This deficiency will be cited,,87411( c)(1) Personnel Requirements – General Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross, see LIC809D.

The following deficiencies were and cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation.
Failure to correct the deficiency(s) and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with the Licensee/Administrator.
Appeal 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: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/08/2023 04:34 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: 08/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)

87411( c) Personnel Requirements – General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's [(observation) and (record review)], Three out of Five staff lacked proof of annual training hours being completed. Records on hours completed each day are unclear, the licensee did not comply with the section cited above in [three] out of { five] staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/01/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure all staff have required intial/annual training hours and all training is clearly documented, able to be counted up as needed. Submit proof of staff's annual training by POC due date of 9/1/2023.

Type B

Section Cited

CCR

87411(c)(1)

87411(c )(1) Personnel Requirements – General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's [(observation) and (record review)], one out of five staff lacked required first aid certification, the licensee did not comply with the section cited above in [one] out of { five] staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/11/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure all staff have required first aid certification training. Submit proof of staff's first aid certification by POC due date of 8/11/2023.

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: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC809 (FAS) - (06/04)

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