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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803588
Report Date: 03/07/2022
Date Signed: 03/07/2022 10:20:46 AM


Document Has Been Signed on 03/07/2022 10:20 AM - 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:COUNTRY ROSE ASSISTED LIVINGFACILITY NUMBER:
496803588
ADMINISTRATOR:ARCHER, LEAHFACILITY TYPE:
740
ADDRESS:2273 WEST HEARN AVENUETELEPHONE:
(707) 495-0801
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:6CENSUS: 4DATE:
03/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Rosa Ascencio (Caregiver)TIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst, Cuadra, arrived unannounced to conduct an Annual Required Inspection – 1 yr. Infection Control inspection to this facility and met with Caregiver, Rosa Ascencio. Licensee, Leah Archer was available by phone and gave permission for caregiver to sign report. LPA conducted a Risk Assessment with staff. LPA/Licensee reviewed PIN 22-05, 22-06, 22-07 & 22-09.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that facility doesn't have posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/staff conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least once a day. Facility is able to accommodate a single room for each resident that needs to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols, but not N-95 fit tested. Staff and residents are not being monitored daily and results not documented. Facility maintains a 30 day supply of medication. Facility has 100% vaccination rate for all staff and residents have received boosters. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. Residents receive outdoor visitation. LPA discussed with Licensee about updated guidance PIN 22-07 about indoor visitation with their families. Licensee was informed about screening, documenting for symptoms and tracking purposes of all residents, staff and visitors. Facility has submitted their Covid Mitigation Plan and approved on 7/20/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are located in an accessible place for staff. Licensee will provide copies of the following by 3/21/22: Administrative Organization (LIC309), Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Lease agreement, Liability insurance & Emergency Disaster Plan (LIC610E).
No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
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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Document Has Been Signed on 03/07/2022 10:20 AM - 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: COUNTRY ROSE ASSISTED LIVING
FACILITY NUMBER: 496803588

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
87468.1(a)(2) Personal Rights of Residents in All Facilities (a) Residents in all RCFE shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, interview and records review Licensee did not ensure that staff and residents are being monitored daily for symptoms of Covid19 and results documented as reflected in facility's mitigation plan and current CCL requirements. This poses an immediate risk to the health, safety and personal rights to the residents in care.
POC Due Date: 03/08/2022
Plan of Correction
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Licensee will ensure Personal Rights of residents are maintained. Licensee agrees to submit proof of training for daily screening and documentation of Covid19 symptoms for all staff to CCL by 3/8/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
LIC809 (FAS) - (06/04)
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