496803588-3-11-2025-21-AS-ECOS-DENRDH-20250311125558

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803588
Report Date: 03/11/2025
Date Signed: 03/11/2025 12:56:29 PM

Document Has Been Signed on 03/11/2025 12:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	COUNTRY ROSE ASSISTED LIVING		FACILITY NUMBER:	496803588
ADMINISTRATOR/ DIRECTOR:	ARCHER, LEAH		FACILITY TYPE:	740
ADDRESS:	2273 WEST HEARN AVENUE		TELEPHONE:	(707) 495-0801
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95407
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	03/11/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:55 AM
MET WITH:	Rosie Asencio- Caregiver		TIME VISIT/ INSPECTION COMPLETED:	01:05 PM

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	Licensing Program Analysts (LPAs) Cuadra and Contreras arrived unannounced to conduct an Annual Required Inspection and met with staff, Rosa Ascencio. Licensee, Leah Archer came to the facility and gave permission for caregiver to sign report. Annual fees are due today in the amount of $495, Licensee notified. LPA/staff initiated a tour of the facility at 9:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Garbage cans located in bedrooms did not have a cover and room 1 had a smell of urine (technical violation issued). Water temperature in resident's bathroom measured at 105.6 degrees F which is within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required grab bars. Kitchen cabinet containing cleaning supplies was locked. Medications were centrally stored and locked. Fire extinguisher charged and serviced as of February 2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have auditory alerts that were functional at time of visit. Last disaster drill was conducted on January 2025. Facility has at least two days of perishable and one week of non-perishable foods. LPAs had a discussion with licensee regarding the benefits of having more food supply (technical advisory issued). At approximate 9:15am LPA/staff observed dry food containers did not have expiration dates. Continues on LIC809C...

Kimberley Mota	TELEPHONE: (707) -588-5051
Ethel Contreras	TELEPHONE: 707-588-5062
	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COUNTRY ROSE ASSISTED LIVING	FACILITY NUMBER: 496803588
	VISIT DATE: 03/11/2025

NARRATIVE

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Continued from LIC809...

File review was initiated at 10:00 am. Three staff files and five resident files were reviewed. Two out of five residents (R1 and R2) care plan needs to be updated (technical violation was issued). Two out of three staff (S1 and S2) did not have health screening and TB results. Staff have required First Aid and CPR certificates. Training hours were complete. Administrator certificate for Administrator Leah Archer # 7009822740 expired on 12/23/24. LPAs reviewed and confirmed that Administrator is currently in the Department's pending list for review. LPA/staff conducted review of medications and their records. Required postings observed.

Licensee to submit updates of the following documents by 3/25/2025: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and a copy of Liability Insurance.
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 staff, Licensee was notified about deficiencies found during today's visit and a copy of the report was given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) -588-5051
LICENSING EVALUATOR NAME: Ethel Contreras	TELEPHONE: 707-588-5062
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2025 12:56 PM - 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
SANTA ROSA RO, 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: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs/Licensee observation, interview and record review, the licensee did not comply with the section cited above in two out of three staff did not have a health screening including TB on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2025
	Plan of Correction
1 2 3 4	Licensee agrees to obtain health screenings for two staff (S1 and S2) and will submit LIC503 health screening form for two staff to CCL by POC due date in order to clear the deficiency.

Type B

Section Cited

CCR

87555(b)(9)

General Food Service Requirements

(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs/Licensee observation and interview, the licensee did not comply with the section cited above in eleven food containers with grains, beans, rice, etc were not storage in a safety manner by not having expiration and open dates on them which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2025
	Plan of Correction
1 2 3 4	Licensee agrees to revise food containers needing dates including open and expiration times and will submit a picture of them to CCL by POC due date to clear the citation.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Kimberley Mota	TELEPHONE: (707) -588-5051
Ethel Contreras	TELEPHONE: 707-588-5062
	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2025 12:56 PM - 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
SANTA ROSA RO, 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: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs/Licensee observation, interview and record review, the licensee did not comply with the section cited above in two out of five residents do not have an updated care plan on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2025
	Plan of Correction
1 2 3 4	Licensee agrees to update resident's care plans and will submit them as proof of correction by POC due date to clear the citation.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Kimberley Mota	TELEPHONE: (707) -588-5051
Ethel Contreras	TELEPHONE: 707-588-5062
	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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