496804217-4-30-2024-21-AS-CCOO-D4TTXR-20240430150733

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804217
Report Date: 04/30/2024
Date Signed: 04/30/2024 03:07:52 PM

Document Has Been Signed on 04/30/2024 03:07 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:	WILLOWS NURSING HOME		FACILITY NUMBER:	496804217
ADMINISTRATOR:	GEOCADIN, DANILO		FACILITY TYPE:	740
ADDRESS:	5926 ANSON DR		TELEPHONE:	(707) 291-9791
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	6	CENSUS: 0	DATE:	04/30/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Danilo Geocadin, Administrator		TIME COMPLETED:	03:22 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) Christi Coppo arrived announced to conduct a pre-licensing inspection and was greeted by applicant Danilo Geocadin. Facility currently does not have residents in care. Facility has fire clearance for six [6] non ambulatory residents. Once obtained, applicant will submit proof of required liability insurance. At approximately 9:30am LPA and Applicant toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed emergency supply of non-perishable food and water. Kitchen has locked cabinet that will be used for medication storage. Kitchen range has child proof knob covers. Items in kitchen that need to be addressed are: kitchen cabinet shelf liners need to be replaced or cleaned as there is yellow and orange film present; portion of counter covered with tape to cover exposed area, tile is missing above cutting board on left hand side of range; drawers on both side of range need a functional lock as drawers will house sharp knives and utensils; screen on kitchen screen door is separating from the frame. Sample menu present in dining area. Cleaning supplies locked under sink in kitchen. LPA observed two [2] rodent traps present in living room. Per Applicant, they had a pest control inspection. Applicant provided LPA with copy of report dated 10/19/2023. Per pest inspection report, various traps placed around the house, in the garage under the heater, under the backyard deck, and technician placed an excluder in the two holes where the entry point was, a trap in front of one small hole located in the garage, and noted their concern for the birds outside. Applicant has two [2] cages of birds on each side of the backyard shed. Pest technician indicated in his report that the birds were messy and throw seeds around, this alone could be attracting the rodents. The technician observed a large hole where the rodents could enter the home. LPA discussed with Applicant that CCL will need a report from the pest control company showing clear findings for all rodents, vermin, and insects before LPA can recommend licensure. Continued on 809C...

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WILLOWS NURSING HOME	FACILITY NUMBER: 496804217
	VISIT DATE: 04/30/2024

NARRATIVE

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Facility is a two story residence with seven [7] bedrooms, four [4] full baths and three [3] half bathrooms. Room #3 downstairs will be dedicated as a staff room, in which the staff will live. The downstairs bedroom located next to the garage, room #1 will be the only double occupancy bedroom at the facility. Room #1 has cracked wood piece extending across the width of the left hand portion of the top of the shower. Dead insects were present on window sill and stuck to the blinds. The upstairs consists of one of the seven total bedrooms and one of the full bathrooms. The upstairs will be the dedicated living space for the applicant and spouse. The facility has a kitchen, dining room, and living room as common areas. All resident rooms are furnished per regulation with a bed, lamp, and bedside table. All resident rooms need a chest of drawers added to be in compliance with regulation. Room #4 and #5 need a chair to be in compliance with regulation. Extra linens and bedding observed. LPA advised trash bins need tight fitting covers. Room #6 has one tile missing at the bottom of each side of the shower, leaving wood open and exposed. Garage houses storage, laundry and emergency supply of water. All room doors leading to the outside have functioning alarms, including the kitchen and front door. Bathrooms have required mats and grab bars.

Water temperatures read at: 112 degrees F in kitchen, 112 degrees F in Room #1, 107 degrees F in main bath, 106 degrees F in room #2, 109 degrees F in room #4, 107 degrees F in room #5, 112 degrees F in room #6, all which are within regulation of 105 & 120 degrees F.

Facility has large outside area for residents to enjoy. However, fence on east side is in disrepair and is a safety hazard. Boards have green film present along bottom of many boards. Boards show indication of weathering, nails are exposed and protruding, and portions of fence are missing. Fence is leaning heavily in areas. The ramp that extends down the west side of the facility, bordering rooms #2.#4. and #5 has sharp end of screws exposed along top and bottom borders, this also poses a safety hazard. Ramp must be repaired so that sharp ends of screws are not exposed. In the front yard of the house along the east side of the property there are wood pieces have have exposed nails, wood pieces to be removed. In back and front corners of east side fence there are piles of discarded items such as push lawn mower, piles of wood, various gardening supplies, bed frame, box spring, dresser and dresser drawers, painting supplies, ladders and step stools, all items in the corners of fence need to be free from discarded items, they must be safe, sanitary and in good repair.

Continued on 809C(2)...

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WILLOWS NURSING HOME	FACILITY NUMBER: 496804217
	VISIT DATE: 04/30/2024

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Continues from 809C...

Smoke and carbon monoxide detectors present and functioning. Two [2] fire extinguishers present and last serviced on 12/8/2023. First aid kit present with all required items. LPA observed all required postings and posters present. Night lights in hallway present.

Items required to be repaired/addressed before licensure:

Fence on east perimeter
Ramp on west perimeter
Kitchen cabinet and shelf liners with film present
Tile above cutting board on left hand side of range
Drawers on both side of range need a functional lock
Screen on kitchen screen door
Piles of discarded items in front and back corners of east perimeter fence
Report from the pest control company showing clear findings for all rodents, vermin, and insects
All resident rooms need a chest of drawers
Room #4 and #5 need a chair
Room #6 one tile missing at the bottom of each side of the shower
Room #1 cracked wood piece extending across the width of the left hand portion of the top of the shower.
Room #1 dead insects present on window sill and stuck to the blinds.
Trash bins need tight fitting covers
Extension cords on west corner of facility
Vent in hallway on ceiling dust cleaned out

Applicant to notify CCL once all repairs complete. LPA will then return to inspect repairs before recommending applicant for licensure. Comp III will be reviewed upon LPA return visit.

Exit interview conducted with Applicant and a copy of this report given.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC809 (FAS) - (06/04)

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