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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803975
Report Date: 11/05/2021
Date Signed: 11/05/2021 03:32:42 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 CAREFACILITY NUMBER:
576803975
ADMINISTRATOR:HERNANDEZ, SALVADOR IVANFACILITY TYPE:
740
ADDRESS:1366 COOLIDGE PL.TELEPHONE:
(530) 312-1356
CITY:WOODLANDSTATE: CAZIP CODE:
95776
CAPACITY:4CENSUS: 1DATE:
11/05/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Salvador Ivan Hernandez, Licensee/AdministratorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Post Licensing inspection at Six Roses Senior Care, on November 5, 2021 at 2:35 PM. LPA met with Administrator/Licensee Salvador Ivan Hernandez. The facility currently has 1 client in care.

Administrator conducted a walk through of facility and LPA observed client rooms were furnished per regulations. LPA observed all walkways and exits to be unobstructed. LPA reminded Licensee about required postings . LPA observed staff wearing masks as a COVID-19 precaution. Facility has at least two days of perishable and one week of nonperishable foods. Facility has space indoors and outdoors for client activities. Administrator has a current and complete file for client, observed by LPA. Disinfectants/toxins are kept locked in a closet and inaccessible to clients in care. Extra linens and paper supplies are available for clients. Medications are kept locked and documented on a Centrally Stored Medication Log. LPA observed fire extinguisher in kitchen which was charged and purchased on 12/21/2021. The facility has 2 operational carbon monoxide detectors, and 7 interactive smoke detectors which were tested and operational. All exterior doors had operational auditory alarms. House temperature was 73 F. Facility has 30 days supply of PPE and Resident has 30 days supply of medication and incontinence supplies

No deficiencies cited at today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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