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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803975
Report Date: 07/27/2022
Date Signed: 07/27/2022 01:34:41 PM


Document Has Been Signed on 07/27/2022 01:34 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: DATE:
07/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria Barajas, Caregiver
and Salvador Hernandez, Administrator via phone		TIME COMPLETED:
01:45 PM
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LIcensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to do an inspection and check on the submittal of the Infection Control Plan. LPA arrived and was screened for Covid-19 symptoms, and results and temperature were documented in log.

There was one caregiver and 2 residents at the facility at the time of inspection; and a visit from hospice agency. The facility was clean and a comfortable temperature. Both residents had just had lunch and were resting in bed. There were soap and paper towels in the restrooms and signage posted reminding residents, staff and visitors to wash their hands for at least 20 seconds.

The kitchen was clean and well-stocked with fresh fruit. The facility was decorated with seasonal decor, which made the setting homelike.

Via phone, LPA discussed with Administrator the submittal of Infection Control Plan and the move-in of a new resident at the end of July.

No deficiencies were found at the time of inspection.
No citations were given.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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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