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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803311
Report Date: 06/22/2021
Date Signed: 06/22/2021 02:33:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PLATINUM RESIDENTIAL CARE HOMEFACILITY NUMBER:
496803311
ADMINISTRATOR:SISNEROS, TOSHAFACILITY TYPE:
740
ADDRESS:1972 DENNIS LANETELEPHONE:
(707) 757-8607
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 6DATE:
06/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Tosha Sisneros-AdministratorTIME COMPLETED:
02:27 PM
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Licensing Program Analyst (LPA) Dina Alviso conducted 1 year required inspection and met with Administrator Tosha Sisneros, and Licensee Mera Shaughnessey The inspection is focused on the Infection Control procedures and practices of this facility.

All visitors, essential 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 and observed for any changes, all information is logged. 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 and staff that do not handle medications. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Administrator and the Licensee had a mask on during the LPA's inspection. Facility has an approved dementia plan of operation. There is an approved hospice waiver for three (3) residents. Mitigation plan was approved by the Department on 3/25/21. Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden;
There were six (6) residents in care at the facility during this inspection.
No deficiencies during today's inspection.
No citations issued.
Exit interview conducted with the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
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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