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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803975
Report Date: 05/17/2022
Date Signed: 05/17/2022 04:28:19 PM


Document Has Been Signed on 05/17/2022 04:28 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 3DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Salvador Hernandez, AdministratorTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. Infection Control inspection of this facility and met with Administrator Salvador Hernandez. 3 clients were present at the facility.

LPA arrived at the facility and was screened for possible Covid-19 exposure and had temperature checked and logged into visitor’s binder, which is kept at a small table at entrance, along with thermometer, hand sanitizer and masks. The facility was found to be clean and at a comfortable temperature of 75 F with all exits free from obstruction, and equipped with door alarms. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Smoke detectors and carbon monoxide detector were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored as per regulations on this day at the time of the visit. Toxins are stored and locked in laundry room. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings.

The backyard was well equipped for visitors during the Summer months to allow for social distancing.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored. Facility is in the process of being N95 Fit tested.

No deficiencies were observed or cited during today's Required 1- Year inspection.

Exit interview was conducted and a copy of this report was left with Salvador Hernandez, Administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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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