576803975-7-14-2021-21-AS-JNAA-C4VLWG-20210713090703

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 576803975
Report Date: 07/12/2021
Date Signed: 07/14/2021 01:37:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	SIX ROSE'S SENIOR CARE		FACILITY NUMBER:	576803975
ADMINISTRATOR:	HERNANDEZ, SALVADOR IVAN		FACILITY TYPE:	740
ADDRESS:	1366 COOLIDGE PL.		TELEPHONE:	(530) 312-1356
CITY:	WOODLAND	STATE: CA	ZIP CODE:	95776
CAPACITY:	4	CENSUS: 0	DATE:	07/12/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Salvador Ivan Hernandez		TIME COMPLETED:	03:40 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 Analysts (LPAs) Karina Canela and Jill Nakagawa conducted a pre-licensing inspection on 07/12/2021. LPAs met with Applicant Salvador Ivan Hernandez, who will be the Administrator when the facility is approved for licensure. The facility has a fire clearance approval from the Woodland Fire Department for 3 non-ambulatory residents and 1 bedridden for a total capacity of 4. Facility will operate with live-in staffing and Licensee will ensure sufficient staffing at all times. During today’s visit LPAs observed the following items: · Lockable separate cabinets for medications, toxin, and knives. · All exits were unobstructed · 7 hardwired smoke detectors, 2 carbon monoxide detectors which were tested and observed to be operational · First Aid kit, night-lights, and flashlights for emergency lighting · Supply of linens, paper products, and hygiene supplies available · Grab bars and non-slip mats in 2 of 2 bathrooms. · Fire Extinguisher charged · Administrator Certification Report continued on LIC 809-C.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SIX ROSE'S SENIOR CARE	FACILITY NUMBER: 576803975
	VISIT DATE: 07/12/2021

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LPAs Karina Canela and Jill Nakagawa notified the applicant that the following corrections must be made in order to proceed with licensure:

· Chest of drawers needed in 2 out 3 bedrooms (bedrooms 2 and 3 on facility sketch)
· Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Client personal rights, Administrator certificate posted, and visitor policy).

The Component III Orientation was completed during today's inspection.

Pre-Licensing is incomplete with above items to be resolved by 7/19/2021. Applicant to submit pictures as proof of correction to Community Care Licensing Department (CCLD) for review. Once corrections are submitted and reviewed by CCLD, LPA will submit the pre-licensing report with proof of corrections to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

LIC809 (FAS) - (06/04)

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