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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803588
Report Date: 02/10/2023
Date Signed: 02/10/2023 09:59:57 AM


Document Has Been Signed on 02/10/2023 09:59 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:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:13 AM
MET WITH:Leah Archer (Licensee)TIME COMPLETED:
10:14 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee Leah Archer. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was screened by staff for Covid-19 which included a temperature check and signing in. LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. Facility continues to screen staff and residents and maintains documentation. Facility has a designated visitation area and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE and have been N95 fit tested. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication and incontinence care supplies. Facility has submitted their Emergency Disaster Plan, Infection Control Plan and Mitigation Plan. At approximate 8:30am LPA/staff observed fire extinguisher has not been serviced since December 2021. Also, approximate 9:00am LPA/staff observed toxins including disinfectants were unlocked and accessible to residents in care under the sink located in resident's bathroom. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational.
Licensee provided copies of the following: LIC 308 Designated Administrative responsibility, LIC 500 Personnel Summary, Liability Insurance and lease agreement.
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. Exit interview conducted with Licensee and a copy of this report was provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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 02/10/2023 09:59 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: 02/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in one out of one fire
extinguisher has not been serviced within the last year which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2023
Plan of Correction
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Licensee to submit pictures of updated tags or receipt showing that fire extinguisher has been serviced by POC due date
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: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/10/2023 09:59 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: 02/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in toxins including disinfectants were unlocked and accessible to residents in care under the sink located in resident's bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2023
Plan of Correction
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Staff immediately locked door where toxins were found. Deficiency is cleared.
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: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3