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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803764
Report Date: 06/02/2021
Date Signed: 06/02/2021 12:41:58 PM

Document Has Been Signed on 06/02/2021 12:41 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PRIMROSE ALZHEIMER'S LIVING INCFACILITY NUMBER:
496803764
ADMINISTRATOR:WOTRING, JOHN JFACILITY TYPE:
740
ADDRESS:2080 GUERNEVILLE RDTELEPHONE:
(707) 578-8360
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 50CENSUS: 32DATE:
06/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:John Wotring-AdministratorTIME COMPLETED:
12:55 PM
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Licensing Program Analysts (LPA), Dina Alviso and Karen Lopez. LPA's are conducting an Annual inspection, on 6/2/2021 at approximately 10:05am, and met with Administrator John Wotring. The inspection is focused on the Infection Control procedures and practices of this facility.

Currently thirty-two (32) residents in care, and three residents on hospice care. Facility specializes in dementia care. Hospice care waiver approved for eight (8) residents. Mitigation plan submitted and approved by the Department on 1/27/21. Fire clearance approval is for fifty (50) non-ambulatory, which includes twelve (12) bedridden approval.

Facility offers activities during the day for those wanting to participate; Pandemic policies are in place. All visitors are screened upon entering the building; All visitors have their temperatures taken and answer all screening questions. Residents are screened daily, and observed for any changes. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Fire extinguishers were serviced and tagged, during today's visit, 6/2/22021. Toxins are stored inaccessible and in locked cabinets. Medications were stored locked making them inaccessible to residents and staff that do not handle medications. The facility has a large sufficient supply of personal protective equipment (PPE). All exit alarms were on exit doors and working properly. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Administrator stated that staff wear masks in the facility, and also when providing care services to the residents in and out of the facility. Administrator had a mask on during the LPA's inspection. Administrator is conducting surveillance covid-19 testing of all staff at 25% every seven days. Administrator stated that the facility is following and operating in compliance with their approved mitigation plan, and in compliance with title 22 regulations as required.
No deficiencies cited today.
Exit interview conducted with Administrator John Wotring.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2021
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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