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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803905
Report Date: 05/09/2024
Date Signed: 05/09/2024 04:48:44 PM


Document Has Been Signed on 05/09/2024 04:48 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ARBOL RESIDENCES OF SANTA ROSAFACILITY NUMBER:
496803905
ADMINISTRATOR:TAPIA, KARINAFACILITY TYPE:
741
ADDRESS:300 FOUNTAINGROVE PARKWAYTELEPHONE:
(707) 566-8600
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:152CENSUS: 86DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Karina Tapia-Interim AdministratorTIME COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA), Alviso, conducted a Required -1 Year visit, on 5/9/24 at approximately 9:20am, and met with Interim Administrator Karina Tapia. LPA also met with Donna Caampued, Health & Wellness Coordinator.

The facility is a licensed continuing care retirement community, consisting of an assisted living building, which includes dementia care services unit, and a skilled nursing building. The LPA is reporting on the assisted living, and dementia unit, in today's visit. There is a total census of eighty-six (86) residents in the assisted living, including the dementia unit. The skilled nursing building is monitored by Department of Health. There are thirty-six (36) patients in the skilled nursing building.

Facility has a dementia plan of operation approved by the Department. Hospice waiver approved for fifteen (15) residents. The facility has a required infection control plan, which is part of the facility's plan of operation. Facility has a required facility emergency disaster plan,.part of the plan of operation. Fire clearance approved for 152 non-ambulatory, of which 25 may be bedridden; Third (3rd) floor is approved for non-ambulatory only.

The LPA toured the facility with the Interim Administrator. All exits were observed to be clear and unobstructed. All common areas, hallways,observed resident rooms, and bathrooms all had sufficient lighting for residents in care. Food supply was found to be sufficient, and LPA observed a food delivery truck leaving an order of additional food supplies. Fire extinguishers were all serviced and tagged, expires 9/6/24. Hot water was checked throughout the building at 113.5, 109.7, 106., 109. degrees Fahrenheit, which is within regulation. Facility was observed to have sufficient paper products, hygiene products, personal protective equipment (PPE), and cleaning/disinfectant supplies.

The LPA will continue this annual at a later date.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
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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