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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
576803975
Report Date:
07/19/2024
Date Signed:
07/19/2024 10:27:25 AM
COMPREHENSIVE INSPECTION
Document Has Been Signed on
07/19/2024 10:27 AM
- 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 CARE
FACILITY NUMBER:
576803975
ADMINISTRATOR:
HERNANDEZ, SALVADOR IVAN
FACILITY TYPE:
740
ADDRESS:
1366 COOLIDGE PL.
TELEPHONE:
(530) 312-1356
CITY:
WOODLAND
STATE:
CA
ZIP CODE:
95776
CAPACITY:
5
CENSUS:
3
DATE:
07/19/2024
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME BEGAN:
09:15 AM
MET WITH:
Salvador Hernandez, Administrator
TIME COMPLETED:
10:26 AM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete the Annual Inspection of Six Rose's Senior Care. There was one staff and 3 residents at the time of inspection.
LPA returned to facility to complete a review of facility's files and to clear the Plan of Correction for the citation issued at the last visit.
LPA reviewed 3 of 3 resident files and found them to be complete. LPA also reviewed 6 of 6 staff files and found them also to be complete.
LPA cleared the POC from the last visit.
There were no deficiencies found at the time of inspection. No citations issued.
SUPERVISOR'S NAME:
Kimberley Mota
TELEPHONE:
(707) 588-5051
LICENSING EVALUATOR NAME:
Jill Nakagawa
TELEPHONE:
707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE:
07/19/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/19/2024
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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