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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803886
Report Date: 02/24/2023
Date Signed: 02/24/2023 03:28:06 PM


Document Has Been Signed on 02/24/2023 03:28 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:H & M'S THE ROSE GARDENFACILITY NUMBER:
496803886
ADMINISTRATOR:GARCIA, MAGGIEFACILITY TYPE:
740
ADDRESS:2370 MELBROOK WAYTELEPHONE:
(707) 546-2429
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: 6DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Licensee/Admin Heherson and Maggie GarciaTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced on 02/24/2023 to conduct a Required - 1 Year inspection and met with licensee/administrator Heherson and Maggie Garcia. The inspection is focused on the Infection Control procedures and practices of this facility. LPA was initially greeted by staff, licensee/administrator arrived shortly.

At primary entrance LPA observed visitor sign-in sheet. LPA conducted walk through of the facility with licensee/administrator and observed COVID postings throughout. Facility was clean and in good repair.
Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. High touch surface areas are disinfected daily. Due to current facility census residents could isolate in their own rooms if they became ill. LPA observed COVID kit with PPE to support a resident in isolation. Sufficient perishable and non perishable food was available. Fire extinguishers were charged and current. Toxins were secured and inaccessible. Medications were centrally stored and locked. Carbon monoxide and smoke detectors were present and operational. Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Fire department inspected fire alarm system in December.

LPA requested licensee/administrator submit the following documents to community care licensing within 30 days of today's inspection: LIC 500, LIC 610E, LIC 9020, LIC 308, Liability Insurance, Admin Certificate

No deficiencies observed during today's inspection.

Exit interview conducted with Heherson and Maggie Garcia. A copy of the report emailed to the licensee/administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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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