496803588-4-24-2024-21-AS-MCUA-D4MMJS-20240424093937

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803588
Report Date: 04/24/2024
Date Signed: 04/24/2024 09:40:17 AM

Document Has Been Signed on 04/24/2024 09:40 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 LIVING		FACILITY NUMBER:	496803588
ADMINISTRATOR:	ARCHER, LEAH		FACILITY TYPE:	740
ADDRESS:	2273 WEST HEARN AVENUE		TELEPHONE:	(707) 495-0801
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95407
CAPACITY:	6	CENSUS:	DATE:	04/24/2024
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Leah Archer (Licensee)		TIME COMPLETED:	09:39 AM

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	An informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager Bethany Moellers, Licensing Program Analyst Marisol Cuadra, and Licensee Leah Archer. The purpose of the informal office meeting was to discuss areas of non-compliance and observed and ongoing Community Care Licensing concerns of the operation of Country Rose Assisted Living #496803588. The Licensee was informed that this informal meeting is a part of the Administrative Action process and that further and/or repeat citations may result in a formal Non-Compliance Plan. The legal administrative action process was explained to attendees which is based on deficiencies found during annual visit conducted on March 21, 2024. Items addressed in today's meeting include but are not limited to patterns and trends in the areas below: · Fire Clearance violation of bedridden bedrooms. · General Food Requirements including good quality of food as stated in regulations. · Incidental medical and dental care services including maintaining Centrally Stored Medication log of resident’s medication as well as medication management. · Reporting Requirements of incidents occurred at the facility were not notified to CCL. · Personnel Records on file must be complete with required documentation. · Current administrator and involvement in the facility operation including their presence on premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation. Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

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: COUNTRY ROSE ASSISTED LIVING	FACILITY NUMBER: 496803588
	VISIT DATE: 04/24/2024

NARRATIVE

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Continued from LIC809...

Documents requested during informal meeting to be submitted to CCL by 04/30/2024:

· Licensee to submit updated LIC500 personnel summary and include all staff specific days/hours on shift, including administrator. Ensure administrator hours are business hours, Monday through Friday (the min 20 hours).

· Licensee to develop policy identifying staff member responsible for ensuring all deficiencies are addressed, special incident report is submitted to designated agencies.

Failure to submit the above documentation may result in the Department seeking further action.

Licensing staff discussed Technical Support Program (TSP) that offers advice, guidance, a review of facility operation, discusses best practice, and required regulation/HSC compliance. Licensee agreed to contact the Department if they consider that benefit of TSP.

No deficiencies cited during today’s informal conference visit. Copy of this report was provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC809 (FAS) - (06/04)

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