496804075-4-4-2023-21-AS-DALO-CQKP48-20230404105844

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804075
Report Date: 04/04/2023
Date Signed: 04/04/2023 10:58:50 AM

Document Has Been Signed on 04/04/2023 10:58 AM - 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:	04/04/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Bana Solomon-Applicant		TIME COMPLETED:	11:10 AM

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 pre-licensing inspection, on 4/4//23 at approximately 9:15AM, and met with applicant Bana Solomon, who will be the facility's Administrator once licensed. 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. The last inspection was on 3/21/23 and there were a few items that needed to be completed; The LPA has observed that the following items are complete. The iron rails on the ramp leading to the front door have been installed, and the gate on the side ramp has been installed as needed. The kitchen has the stove/range knobs covered so they are inaccessible to future residents in care. The kitchen has a cabinet that can be locked for toxins/cleaners to ensure they are inaccessible to future residents in care. There was a cabinet that is locked and stores the knives. There is a key code lock and key access to a small storage closet in the hallway that will be used to secure medications, and keep them locked and inaccessible to future residents. The two bathrooms have mirrors up, and paper towel holders. The rooms have furnishings for resident use. All postings were up and visible to all as you enter the home, on the wall to the right. 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: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

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: 04/04/2023

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The LPA observed the hallway fire door working properly during the inspection. There were small lamps on the night stands in resident rooms, and the applicant will monitor these ensuring the lamps are bright enough for the future residents in care; The resident rooms do also have ceiling lights. The applicant had the garage cleared and arranged as needed; The garage stores cleaners, toxins, water, overflow food supplies, and the 72 hour shelter in place food supply.

Bana Solomon completed component III orientation on 3/21/23.

The LPA didn't observe any health and safety hazards during today's inspection, 4/4/23. The LPA will forward a copy of the pre-licensing inspection to the Application Unit Analyst; The Application Unit Analyst will contact the applicant with the status of the application.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC809 (FAS) - (06/04)

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