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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576803975
Report Date: 06/10/2024
Date Signed: 06/10/2024 01:01:22 PM


Document Has Been Signed on 06/10/2024 01:01 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:5CENSUS: 3DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Salvador Hernandez, AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced 1-Year Required inspection at Six Roses Senior Care, on June 10, 2024 at 10:30 AM. 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. Facility has at least two days of perishable and one week of nonperishable foods. LPA observed unsecured drawer in kitchen containing knives (see 809-D). Facility has outdoor space for clients including a patio with table, chairs and umbrella for shade. 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 07/19/2023. The last fire drill was held on 06/02/2024 to include new resident and their family. 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. Hot water temperature measured a maximum of . which is within regulation of 105-120 degrees F. Facility has 30 days supply of PPE and Resident has 30 days supply of medication and incontinence supplies.

(Continued on 809-D)
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 06/10/2024 01:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 576803975

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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87705 Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia:
Based on LPAs observations, the Licensee did not comply with the section cited above. LPAs observed knives and other sharp objects in an unlocked drawer in the kitchen accessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
POC Due Date: 06/10/2024
Plan of Correction
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Licensee to immediately remove knives from drawer that is accessible to residents and lock in a secured storage area inaccessible to residents in care, as well as conduct training re: regulation "Persons with Dementia 87705(f)(1)" with proof submitted to Community Care Licensing (CCL) by POC due date of 10/14/2024..
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 576803975
VISIT DATE: 06/10/2024
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(Continued from 809)

LPA will return at a later date to conduct a file review of personnel and resident files and complete annual inspection.


Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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