496804075-3-21-2023-21-AS-DALO-CQ5QVG-20230321123019

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804075
Report Date: 03/21/2023
Date Signed: 03/21/2023 12:31:27 PM

Document Has Been Signed on 03/21/2023 12:31 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:	WINDROSE CARE HOME		FACILITY NUMBER:	496804075
ADMINISTRATOR:	SOLOMON, BANA		FACILITY TYPE:	740
ADDRESS:	1759 WINDROSE LANE		TELEPHONE:	(707) 867-1770
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 0	DATE:	03/21/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Bana Solomon-Applicant		TIME COMPLETED:	12:35 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, conducted a prelicensing inspection, on 3/21/23 at approximately 8:55AM, and met with applicant Bana Solomon, who will also be the facility's designated Administrator. RCFE Administrator Certificate #6063962740 -expires 8/12/2024. Facility is fire cleared for six(6) non-ambulatory, which includes one(1) bedridden, effective 1/30/23. Applicant has an approved hospice waiver for six(6) residents. Applicant has an approved dementia plan of operation. Applicant has submitted an infection control plan for the home as required. There are two fire extinguishers, inspected and tagged as required- expires 1/25/24. All nine(9) smoke alarms were working appropriately during the inspection. There are two(2) carbon monoxide detectors that were working appropriately during the inspection. All exits were unobstructed during the inspection. All exit doors had auditory alarms for use once the home is operating; All exit auditory alarms were working appropriately during the inspection. Backyard gate is self latching and opened appropriately. There is a ramp coming off the kitchen slider door that leads to the backyard fire exit leading out to the front of the home. The backyard has a table and chair set for resident use. The home also has a front door ramp for use as needed. All bathrooms had grab bars as required, and non-slip flooring in showers for resident use. The hallways had night lights for resident use. The facility had furnishings for resident use. Facility has all necessary and required utilities on and operating appropriately. All kitchen appliances were new and working appropriately. Hot water was checked at 114. F which is within regulation. Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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: WINDROSE CARE HOME	FACILITY NUMBER: 496804075
	VISIT DATE: 03/21/2023

NARRATIVE

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Applicant completed Component III Orientation during the prelicensing inspection.

Applicant's front door ramp needs the railings to be installed; Applicant has an appointment set up for this to be done. The applicant will also be installing some form of gate or railing where there are two steps that drop down from the side of the resident room in the front of the home. The applicant will be choosing where the medications will be stored and install a locking mechanism to ensure medications will be inaccessible to residents in care. Applicant will choose where they will be storing knives in the kitchen and install a locking mechanism to ensure they are inaccessible to residents in care. Applicant will finish putting things together and up as discussed such as the paper towels, mirror/mirror cabinet in the bathrooms. Posting up all required documents as discussed. The fire door in the home didn't close when activated; Applicant will have this checked and ensure it is working appropriately. Ensure sufficient lighting in resident rooms, such as lamps for resident night stands. Installing a locking mechanism on a cabinet in the kitchen to store some disinfectant cleaners/toxins for staff use as needed; Other cleaners/toxins will be stored in the garage and inaccessible to residents in care.

The applicant will contact LPA Alviso when the items listed above are complete;
LPA will schedule another prelicensing continued inspection to reinspect as needed.
The applicant may contact the LPA at the contact number provided if there are any questions to the above information.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC809 (FAS) - (06/04)

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