496803764-4-27-2023-21-AS-DALO-CRB3C7-20230427180729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803764
Report Date: 04/27/2023
Date Signed: 04/27/2023 06:07:34 PM

Document Has Been Signed on 04/27/2023 06:07 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 INC		FACILITY NUMBER:	496803764
ADMINISTRATOR:	WOTRING, JOHN J		FACILITY TYPE:	740
ADDRESS:	2080 GUERNEVILLE RD		TELEPHONE:	(707) 578-8360
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 50		CENSUS: 33	DATE:	04/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	John Wotring-Administrator		TIME COMPLETED:	06:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Alviso, is conducting a Required 1-Year visit, and met with Administrator John Wotring on 4/27/23 at approximately 9:35am. There are thirty-three residents in care at this time. Facility specializes in dementia care. Hospice care waiver approved for eight (8) residents. Facility has submitted the required Infection Control Plan, this is now part of the plan of operation. Fire clearance approval is for fifty (50) non-ambulatory, which includes approval for twelve(12) bedridden. LPA toured the facility with the Administrator. The facility is sprinkled, and has a hard wired smoke alarm system. The facility has four(4) carbon monoxide detectors. All exits with delayed egress were on and working properly during the inspection. Fire extinguishers, seven(7) were serviced and tagged as required- expires 6/8/23. Facility has the fire extinguishers scheduled annually to be serviced and tagged before they expire. The facility exits were all free and clear of obstruction. Hot water was checked at 109.F which is within regulation. All bathrooms inspected were clean, had grab bars, and non-slip mats/flooring in the showers. Resident and visitor bathrooms were clean and orderly. Resident rooms inspected were clean and orderly. LPA observed staff using a rug cleaner machine to clean the rug in resident rooms due to incontinence clean-up and maintenance. The facility has a sufficient supply of cleaners and disinfectants for use as needed. LPA observed other staff assisting residents with care services as needed. Facility has a sufficient supply of hygiene products, paper products, and a sufficient supply of personal protective equipment(PPE) for use as needed. Continued on LIC809C.....

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

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: PRIMROSE ALZHEIMER'S LIVING INC	FACILITY NUMBER: 496803764
	VISIT DATE: 04/27/2023

NARRATIVE

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LPA observed activities going on with residents in care; LPA observed a guest guitarist come in, play music, and sing. LPA observed residents that were participating in the music activity. There was sufficient lighting in hallways, bathrooms, common areas, and resident rooms. LPA observed kitchen staff prepping for the lunch meal, and staff in the dining area setting up the tables. LPA observed a sufficient supply of food, perishable and non-perishable. Medications were observed to be in a locked and secured medication room; Only staff that are trained to handle medications have access to this room. Toxins/cleaners were locked up and inaccessible to residents in care. Facility was observed to be clean and orderly.

LPA reviewed twelve(12) out of twelve(12) resident files. Resident files were complete.

LPA reviewed twelve(12) out of twelve (12) staff files. Staff files were complete. All staff have required criminal record clearance. All staff that are required to have first aid certification were current. There are staff that also have CPR certification as required. Staff have required training.

LPA is requesting the following documents be updated and submitted by 5/27/23:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to provide all information in all boxes as required)
Copy of LIC400 Handling of Client Cash Resources, include copy of surety bond.
Copy of Current Liability Insurance
Copy of current Administrator Certificate

No deficiencies cited today.
Exit interview conducted with Licensee/Administrator John Wotring.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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