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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803764
Report Date: 04/03/2024
Date Signed: 04/03/2024 04:31:26 PM

Document Has Been Signed on 04/03/2024 04:31 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:
ADMINISTRATOR/
DIRECTOR:		WOTRING, JOHN JFACILITY TYPE:
740
ADDRESS:2080 GUERNEVILLE RDTELEPHONE:
(707) 578-8360
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 50CENSUS: 34DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:John Wotring-AdministratorTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA), Alviso, conducted a Required- 1 Year visit, and met with Administrator John Wotring on 4/3/24 at approximately 9:30am.

Facility specializes in dementia care. Hospice care waiver approved for eight (8) residents. Facility has a required infection control plan. Facility has a required emergency disaster plan. Fire clearance approval is for fifty (50) non-ambulatory, which includes approval for twelve(12) bedridden.

The LPA toured the facility with Administrator John J. Wotring. All exits were clear and unobstructed. The facility is sprinkled, and has a hard wired smoke alarm system. The facility has four(4) carbon monoxide detectors. All fire extinguishers were serviced and tagged as required, expires 6/1/24. All exits with delayed egress were on and working properly during the inspection. All bathrooms inspected were clean, had grab bars, and non-slip mats/flooring in the showers.

LPA observed activities going on with residents in care. Resident rooms inspected were clean and orderly. All resident rooms inspected had sufficient lighting, and all common areas of the facility had sufficient lighting for residents in care. The lights in all hallways are able to be dimmed in the evenings as needed. Food supply was sufficient. LPA observed other staff assisting residents with care services as needed. Facility has a sufficient supply of hygiene products, paper products, cleaners, and a sufficient supply of personal protective equipment (PPE) for use as needed. Facility kitchen, food storage areas, and dining area was observed to be clean and orderly. Medications were observed to be stored appropriately as required, and all medications were inaccessible to residents in care. Cleaners/disinfectants were locked and inaccessible to residents in care. Facility has required 72 hour shelter in place supplies.

Continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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: 04/03/2024
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LPA reviewed nine (9) staff files. All staff files were complete. All staff had required training. All staff had criminal record clearance. LPA reviewed ten (10) resident files.

Deficiency identified from resident file reviews.
Five (5) resident files lacked required annual medical assessments. Deficiency will be cited, 87705(c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs, see LIC809D.

LPA is requesting the following documents be updated and submitted 5/3/24.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate when received

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator/Licensee John J. Wotring.
Appeal Rights provided to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/03/2024 04:31 PM - It Cannot Be Edited


Created By: Dina Alviso On 04/03/2024 at 03:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PRIMROSE ALZHEIMER'S LIVING INC
FACILITY NUMBER: 496803764

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705(c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's file reviews,, the licensee did not comply with the section cited above in [5] out of [10] files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2024
Plan of Correction
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Administrator to ensure that the facility obtains updated medical assessments on residents, R3, R4, R5, R7, and R10. Submit plan of correction, including copies of resident assessments by 4/30/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


LIC809 (FAS) - (06/04)
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