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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803588
Report Date: 03/21/2024
Date Signed: 03/21/2024 01:12:31 PM


Document Has Been Signed on 03/21/2024 01:12 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
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:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Rosa Ascencio (caregiver)TIME COMPLETED:
01:27 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Caregiver, Rosa Ascencio. Licensee, Leah Archer was available by phone and gave permission for caregiver to sign report. Required postings were observed. Contact information was reviewed.

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. Water temperature in resident's bathroom measured at 114.7 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 2024. 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 February 2024. Facility has at least two days of perishable and one week of non-perishable foods. At approximate 9:15am LPA/staff observed one can of dark red kidney beans expired as of May 2023, one can of mixed vegetables expired as of 1/21/2024 and a classic yellow mustard expired as of 5/1/2021.

File review was initiated at 9:30 am. Three staff files and five resident files were reviewed. One out of five residents (R1) care plan needs to be updated a technical violation was issued. Also, LPA had a discussion with Licensee via phone about medical assessments and mild cognitive diagnosis because some residents have not been evaluated for a couple years. Licensee agreed to have resident re-assessed by their physician to confirm that they have the same diagnosis, and technical advisory was issued. Staff have required First Aid and CPR certificates. However, one out of three staff (S1) file is missing, but LPA confirmed that S1 has been associated and cleared in Guardian website as of 3/14/24. Licensee confirmed to LPA that S1 just started a week ago, and ensured to LPA that they are only shadowing staff. LPA explained to Licensee that S1 needs to have required documentation on file. Administrator's certificate for Leah Archer 6033354740 expires 12/23/2024. Continued on LIC809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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: 03/21/2024
NARRATIVE
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Continued from LIC809...
At approximate 9:45am LPA/staff conducted a spot of medications and their records were reviewed. However, five out of five resident's (R1, R2, R3, R4 & R5) medications were not entered into the Centrally Stored Medication log. Per staff, R2 was hospitalized between March 7, 2024 and discharged on March 12, 2024, but LPA reviewed incident reports for this facility submitted to CCL and the Department was not notified about R2's hospitalization. The following medication prescribed to R2 have not been given as prescribed by their physician: Ezetimibe 10mg (1 tab by mouth at bedtime), Trazadone HCL 150mg (2 tabs by mouth at bedtime), Carvedilol 12.5mg tab (1 tab by mouth twice daily), Lisinopril 40mg (1 tab by mouth daily), tradjenta 5mg (1 tab by mouth daily), start dates of medication had discrepancies with amount of medication on hand.

At approximate 10:30am, LPA/staff observed that resident (R2) who is bedridden is occupying room #2, which is not cleared by the Fire Department as a bedridden room. On 1/16/2020, the facility was granted a fire clearance for five non-ambulatory and one bedridden client that could occupy bedroom #1 or 4. However, during the physical tour of the facility and records review of residents in care, it was observed R2 occupying room #2. Licensee is operating outside the limitation of the license by accepting a bedridden resident in a non-ambulatory room. LPA/Licensee discussed the issue with R2 and provide the option to relocate resident to a bedroom cleared by the fire marshal for bedridden residents. Licensee agrees to discuss the issue with R2 to provide R2 with the option to move to a bedroom cleared by the fire marshal for bedridden residents or provide another option to CCL that would allow Bedroom #2 has fire clearance for bedridden residents. According to the licensee, R2 is not bedridden and they will reach out to R2's physician to obtain an updated physician's report (LIC602). During the visit, LPA spoke with R2 who expressed that they are not fully bedridden and they are in agreement to obtain an updated medical assessment. As a result of the fire clearance violation, an immediate civil penalty in the amount of $500 is issued today.

Licensee to submit updates of the following documents by 3/28/2024: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E) 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 was conducted over the phone with Licensee who was informed that the Department will be scheduling an informal office meeting to address areas of concerns and overall compliance of the facility and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/21/2024 01:12 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
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: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/staff observation, records review and interview with licensee and resident (R2) in care, the licensee did not comply with the section cited above in one out of five residents (R2) who is bedridden was properly located in a bedroom that it was cleared by the Fire Department as a bedridden room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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 Licensee to certify on LIC 9098 R2 has been relocated to a bedridden room or provide another option to CCL that would allow R2 occupy room#2 by POC due date to clear the citation.
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/staff observations and interviews with the licensee, the licensee did not comply with the section cited above in three food items located in the food pantry of the facility that were found expired which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Facility staff immediately discarded the cans identified as expired. Licensee will develop a facility policy on this food requirement and review with each staff. Licensee agrees to submit the policy to CCL as proof of correction by POC date.
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: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8


Document Has Been Signed on 03/21/2024 01:12 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
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: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/staff observation, records review and interviews with the licensee, the licensee did not comply with the section cited above in one out of five residents (R2) when spot of medications and their records were reviewed. R2 have not been given their medication as prescribed by their physician which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Licensee to ensure all residents receive their medication as prescribed by their physician. Licensee agrees to submit a plan of how they will ensure medication is properly given to the residents as prescribed by their physician 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: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 03/21/2024 01:12 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
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: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s records review and interviews conducted with Licensee did not ensure that CCL was notified of incident involving R2's hospitalization, which poses a potential health & safety risk to residents in care.
POC Due Date: 04/05/2024
Plan of Correction
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Licensee to ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Administrator to review regulation, and will conduct training for all staff on reporting requirements. Signed statement that the regulation was reviewed & sign in sheet for all staff trained to be submitted by POC due date.
Type B
Section Cited
CCR
87412(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/staff observation, records review and interview with licensee, the licensee did not comply with the section cited above by not ensuring that staff (S1) had a complete personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Licensee to ensure that all staff have a complete file with all personnel records required by Title 22 Regulations # 87412 (a) at the facility for CCL to review. Licensee to submit CCL with a LIC 9098 self-certification that staff files are complete according to regulations by POC due date.
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: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 03/21/2024 01:12 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
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: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/staff observation, records review and interview with the licensee, the licensee did not comply with the section cited above in five out of five resident's medications where not entered into the Centrally Stored Medication log accordingly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Facility to submit LIC9098 self-certifying they have conducted staff training on how to properly keep records of medications on CSML to CCL by POC due date to clear the deficiency.
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: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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