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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803737
Report Date: 03/16/2022
Date Signed: 03/16/2022 12:57:38 PM


Document Has Been Signed on 03/16/2022 12:57 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:SUNRISE VILLA SANTA ROSAFACILITY NUMBER:
496803737
ADMINISTRATOR:OLSON, KATHLEENFACILITY TYPE:
740
ADDRESS:4225 WAYVERN DRTELEPHONE:
(707) 538-2590
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:114CENSUS: 69DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Cecilia Dauth, Laura Lopez, Teresa WeertsTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required – 1 Year inspection at approximately 9:00 AM and was greeted by reception. LPA was screened for COVID by staff. LPA met with Cecilia Dauth (Executive Director), Laura Lopez (Memory Care Director), and Teresa Weerts (Health Services Director). There are currently 38 residents in assisted living and 31 in the memory care unit.

LPA toured facility with executive director and health services director. The facility was found to be clean and a comfortable temperature. Toxins were locked and inaccessible to residents in care. Facility has necessary personal protective equipment (PPE) to support a resident in isolation. All assisted living apartments are private therefore residents could isolate in their own apartment if necessary. Resident bathrooms contain necessary grab bars and non-slip floors. Hand sanitizer was observed throughout the facility. Medication is centrally stored and locked. Bedrooms are equipped with lighting and proper bedding that is clean and in good repair.

Staff were observed to be wearing masks. Staff were N95 fit tested as well as given infection control training internally. All but two residents are fully vaccinated. All but one staff are fully vaccinated who has a documented exemption. Staff are discouraged from coming in to work if they feel ill. Activity schedule was observed. Visitors are screened and sign in at front entrance, an antigen test is provided if necessary. Dining room is open for service and allows for social distancing. Visitors can visit indoors. Fire extinguishers were last inspected January 22, 2022. LPA requested the following documents: Emergency Disaster Plan, Liability Insurance, Personnel Report, and Designation of Facility Responsibility.

Exit interview conducted with executive director and a copy of this report printed for the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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