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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804280
Report Date: 01/10/2025
Date Signed: 01/10/2025 05:33:20 PM

Document Has Been Signed on 01/10/2025 05:33 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:
496804280
ADMINISTRATOR/
DIRECTOR:
TAPIA, KARINAFACILITY TYPE:
740
ADDRESS:300 FOUNTAINGROVE PARKWAYTELEPHONE:
(877) 295-3747
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 110CENSUS: 94DATE:
01/10/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Karina Tapia-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Alviso, conducted a pre-licensing inspection, on1/10/25 at approximately 12:50pm, and met with Administrator Karina Tapia, Administrator. Component III orientation was completed with Administrator Karina Tapia, today 1/10/25.

Applicant has a fire clearance approval for one hundred and ten (110) non-ambulatory, of which 30 may be bedridden. The applicant has been approved for twenty-five (25) hospice residents. The facility has an approved dementia plan of operation. The facility has a required infection control plan and a required disaster emergency plan.

The facility site consists of a three story assisted living building, which includes a memory care unit. Memory care unit has delayed egress, and a locked perimeter courtyard for resident use. LPA observed sufficient furnishings on-site throughout the facility for resident use. The kitchen has a sufficient supply of food for residents in care. The grounds were free of any apparent hazards, and exits were clear. No bodies of water. No firearms. LPA observed medication room for assisted living area, and a medication room in the memory care unit. Facility had emergency supplies, including food and water, to meet requirement for the 72 hour shelter in place. Postings noted to be current and in compliance with regulations, including the complaint poster and ombudsman poster. Fire extinguishers were serviced and tagged as required. Hot water was checked at 110.6 degrees Fahrenheit.

There are deficiencies that were observed during the pre-licensing inspection, these will be cited on the current license, Arbol Residences of Santa Rosa- 496803905, see case management report dated, 1/10/25.

Once all deficiencies cited are corrected by current licensee, and plan of corrections (POCs) are submitted to the Department as required, LPA will review corrections, and may make an inspection visit to clear POCs. Once all deficiencies are cleared the LPA will notify the application unit The application unit analyst will notify the applicant of the status of their application.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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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