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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803975
Report Date: 07/06/2023
Date Signed: 07/06/2023 05:04:36 PM


Document Has Been Signed on 07/06/2023 05:04 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:
07/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Salvador Ivan Hernandez, AdministratorTIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced 1-Year Required inspection at Six Roses Senior Care, on July 6, 2023 at 2:40 PM. LPA met with Administrator/Licensee Salvador Ivan Hernandez. The facility currently has 3 clients 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. The facility was decorated for the recent Fourth of July holiday. 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 clients, 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 05/01/2023. The facility has 1 operational carbon monoxide detector, 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: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
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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