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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803975
Report Date: 09/20/2022
Date Signed: 09/20/2022 12:21:19 PM


Document Has Been Signed on 09/20/2022 12:21 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:
09/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Salvador Hernandez, Administrator/LicenseeTIME COMPLETED:
12:30 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 and the request by the Licensee for a change in . LPA arrived and was screened for Covid-19 symptoms, and results and temperature were documented in log.

There was one caregiver and 3 residents at the facility at the time of inspection; two were up enjoying television and one resident was in bed resting. The facility was clean and a comfortable temperature. The facility was decorated for Fall, with garlands of leaves and pumpkins. The residents expressed they liked the homelike atmosphere. The kitchen was clean and well-stocked with at least a two-day supply of perishables and a 7-day supply of non-perishables. There was soap and paper towels in the restrooms and signage posted reminding residents, staff and visitors to wash their hands for at least 20 seconds. A sign requiring masks upon entry was posted at the front door.

LPA discussed the submittal of the Infection Control Plan, the Monkey Pox Control Plan. Licensee is requesting to change staff room to resident room. LPA will contact Fire Department.

No citations were given.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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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