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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803764
Report Date: 03/23/2022
Date Signed: 03/23/2022 10:59:57 AM

Document Has Been Signed on 03/23/2022 10:59 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: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: DATE:
03/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:John Wotring-AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analysts (LPA), Dina Alviso is conducting a case management inspection, on 3/23/22, at approximately 10:00am, and met with Administrator John Wotring. The case management is to obtain more information on a resident incident reported by the facility Administrator.

The LPA spoke with the Administrator and reviewed the incident and how the incident has been addressed. The Administrator will submit the additional information requested by the LPA during the discussion regarding the resident incident. The Administrator stated he will be conducting an Elder Abuse Training with all staff, and will submit proof of training to the Licensing office.

Per LPA's review, Administrator has reported the incident to all agencies as required, and completed and submitted all required report forms.

There are no deficiencies cited today.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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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