Routine inspection·July 31, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Fikre Gurja arrived later, certificate #7029598740 expires 1/7/27. Facility roster was reviewed. At approximately 9:30am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Most food was found to be stored in a safe manner with open items covered, some items such as applesauce and spaghetti sauce were opened without opened dates present. Kitchen cabinet under sink was locked. Kitchen drawer with sharp knives locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. Resident room #1 smelled of urine, noticeable when entering the facility . LPA advised of regulation for Managed Incontinence 87625. LPA advised that residents must be kept clean and dry and also their bedding must be kept clean and dry. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 115 degrees F in the kitchen and 114.5 degrees F in the hall bathroom which is within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 6/19/24. LPA discussed with Admin that fire extinguishers need to be serviced annually. However, fire extinguisher showing as fully charged. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drills were conducted with each staff member in May and June of 2025, LPA observed all training dates for respective staff were within the quarter. Facility has a backup generator for use during a power outage. Continued on 809C... Continued from 809... Facility's backyard perimeter fence in disrepair in several places but primarily on the back and right hand side (if facing the backyard). Planks are loose, have fallen, are missing, have nails exposed, and have an appearance of dry rot. Backyard also has pile of discarded chairs and other items for disposal piled up on side of shed. Ramp on right hand side of facility has lifting boards needing repair. LPA and Admin discussed repairing the fence such that it is sturdy and safe. Admin advised he is waiting for trash pile to be picked up by the City of Santa Rosa. LPA advised Admin can also take to the dump, if city is taking an extended period of time. At approximately 11:00am LPA conducted a review of two [2] resident records. LPA observed resident (R1) in room #1 to have full bed rails. Per Admin, R1 was on hospice beginning 12/30/24 but graduated from hospice on 6/27/25. LPA advised that full bed rails are a prohibited condition unless resident is on hospice and has a hospice care plan that specifies the need for full bed rails. LPA reviewed hospice care plan, plan does not indicate the need for full bed rails ( d eficiency cited, see 809D ). Per R1 physician's report and per Admin, R1 is bedridden. LPA advised facility does not have fire clearance for bedridden residents. Admin showed LPA form filled out for Santa Rosa Fire Dept (SRFD) indicating R1 was using oxygen and Admin checked a box for bed bound on the form, however fax transmission to Fire Dept not produced for LPA. Admin did produce email sent to SRFD notifying them that R1 was using oxygen, but nothing noted about bed bound or bedridden status ( deficiency cited, see 809D ). LPA reviewed R1's appraisal. Per, Admin, resident appraisal are completed by residents' responsible parties. LPA discussed with Admin that he needs to complete the appraisals. LPA discussed with Admin that it is good practice to complete the appraisal himself, this will allow him to determine if a potential resident is compatible with other residents and/or if facility staff will be able to meet the care needs of resident, among other valuable uses. Resident's (R2's) physician report shows faxed dated of 8/1/24, is missing diagnosis and missing physician signature and date. LPA advised Admin to be sure to review residents' physician reports/medical assessments once received in order to review changes in ambulatory status and diagnoses, as well as making sure it is signed and dated. LPA also advised that a medical assessment must be completed Continued on 809C(2)... Continued from 809C... annually, regardless of diagnosis, per regulation 87463(h). Most current appraisal for R2 completed 2022 ( deficiency cited, see 809D ). At approximately 12:30pm LPA conducted review of five [5] staff records. LPA discussed with Admin Health and Safety Code (HSC) 1569.625 (b)(1) and (2) and HSC 1569.625(c). LPA advised of subject matters to be covered in training. At approximately 2:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. LPA went over the requirement to keep a PRN MAR/log that meets the requirements of regulation 87465. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given