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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804217
Report Date: 06/12/2024
Date Signed: 06/12/2024 03:38:30 PM


Document Has Been Signed on 06/12/2024 03:38 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 HOMEFACILITY NUMBER:
496804217
ADMINISTRATOR:GEOCADIN, DANILOFACILITY TYPE:
740
ADDRESS:5926 ANSON DRTELEPHONE:
(707) 291-9791
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: DATE:
06/12/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Danilo Geocadin, ApplicantTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Christi Coppo had an office meeting with Applicant Danilo Geocadin for the purpose of conducting review of Comp III. Applicant has provided LPA with videos and pictures of items that were identified as needing repair during CCL Pre-Licensing inspection conducted at Willows Nursing Home on 4/30/2024. The following items were shown to be corrected/ addressed:

Items required to be repaired/addressed before licensure:
  • Fence on east perimeter replaced
  • Ramp on west perimeter repaired
  • Kitchen cabinet and shelf liners are new and clean
  • Tile above cutting board on left hand side of range has been replaced
  • Drawers on both side of range have a functional lock
  • Screen on kitchen screen door replaced
  • Piles of discarded items in front and back corners of east perimeter fence have been removed
  • Report from Orkin pest control company showed clear findings for all rodents, vermin, and insects
  • All resident rooms have a chest of drawers
  • Room #4 and #5 have a chair
  • Room #6 tiles have been replaced 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 has been removed and repair was conducted
  • Room #1 dead insects on window sill removed and blinds were cleaned.
  • Trash bins all have tight fitting covers
  • Extension cords on west corner of facility removed
  • Vent in hallway on ceiling is now clean

Continued on 809C...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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: 06/12/2024
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All items indicated on Pre-Licensing Inspection report, dated 4/30/2024, as needing repairs/corrections have been repaired/corrected satisfactorily. Additionally, LPA called the Orkin Pest Company to verify that the handwritten note on the pest report applicant provided to LPA was accurate. The note indicated that the "birds that the applicants have as pets have a new area at which they are housed; this area is safer for rodents to not invade the home."

Comp III reviewed, exit interview conducted with Applicant, and a copy of this report given. LPA will submit facility's application for approval.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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