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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803764
Report Date: 03/29/2022
Date Signed: 03/29/2022 12:29:39 PM

Document Has Been Signed on 03/29/2022 12:29 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: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: 35DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:John Wotring-AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Dina Alviso, is conducting a Required 1-Year inspection, and met with Administrator John Wotring. The inspection is focused on the Infection Control procedures and practices of this facility.

Currently thirty-five (35) residents in care. Facility specializes in dementia care. Hospice care waiver approved for eight (8) residents. Mitigation plan submitted and reviewed by the Department. 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; LPA observed a group activity exercising class during the inspection. All visitors and staff are screened upon entering the building; All visitors have their temperatures taken and answer all screening questions, all information is logged. Residents are screened daily, and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Fire extinguishers were serviced and tagged as required, dated 6/2/21. Toxins are stored inaccessible and in locked cabinets. Medications were stored locked making them inaccessible to residents in care. 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, and LPA observed all staff had masks on during the LPA's inspection. Administrator stated that the facility is following and operating in compliance with the facility mitigation plan, and in compliance with Department PINs, and title 22 regulations/H&S Code 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: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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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