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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803588
Report Date: 01/27/2023
Date Signed: 01/27/2023 09:37:50 AM


Document Has Been Signed on 01/27/2023 09:37 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: 5DATE:
01/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Rosie Ascencio (Staff)TIME COMPLETED:
09:52 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Rosie Ascencio. Licensee, Leah Archer was available by phone and gave permission for caregiver to sign report.

LPA is following up on a new admission of resident (R1) who appears to have some behavioral tendencies. LPA obtained a copy of R1’s care plan, admission agreement and pre-appraisal. LPA/staff toured the facility and observed that R1 have their own room and they are ambulatory. Licensee is worked closely with their Responsible Party discussing the options available for R1’s behavioral plan to ensure that all residents are protected and it was agreed by both parties after a meeting conducted on January 19, 2023 that the facility is not a good fit for R1. On 1/26/23 CCL received a 30-day unlawful eviction notice email. During today's visit, LPA discussed with Licensee the eviction process regulation and Licensee agreed to re-issue the eviction notice with corrected items. LPA also requested to review current LIC500 Personnel Report and Licensee told LPA that the facility file was not available in the facility for LPA to review which is not in compliance with Title 22 regulation. Per Licensee, she is ensuring to have adequate staffing at all times to meet needs of all residents in care. LPA observed two staff providing care and supervision to residents in care. Licensee agreed to submit updated LIC500 to CCL for LPA’s review.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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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Document Has Been Signed on 01/27/2023 09:37 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: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited

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87412 Personnel Records (g) All personnel records shall be maintained at the facility & shall be available to the licensing agency for review. (1) The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency at the facility as specified in Section 87412(f).
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Licensee agrees to submit self certification that all resident/staff files are accessible for review and contain all required documents by POC due date.
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Based on observation, interview and record review, the licensee did not comply with the section cited above not having records available for Licensing to review during visit including updated personnel report which poses a potential health and safety risk to persons in care.
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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: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
LIC809 (FAS) - (06/04)
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