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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201382
Report Date: 10/31/2024
Date Signed: 10/31/2024 01:09:49 PM

Document Has Been Signed on 10/31/2024 01:09 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ROSEMONT GARDENSFACILITY NUMBER:
019201382
ADMINISTRATOR/
DIRECTOR:		LEUNG, BELINDAFACILITY TYPE:
740
ADDRESS:1345 CLARKE STREETTELEPHONE:
(510) 483-0150
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 45CENSUS: 29DATE:
10/31/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Jeffery Tong, Backup Administrator TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analysts (LPA) J. Clancy-Czuleger and P Manalo, conducted an unannounced visit to the facility for the purpose of a Pre-Licensing evaluation. LPA was greeting by Irene De Leon, Facility Manager. Administrator, Jeffrey Tong Backup Administrator arrived later.

An application was submitted to Community Care Licensing Department (CCLD) for a change of ownership of Residential Care for Elderly 60 years and above. The requested capacity is for (45) Residents, (4) ambulatory and (41) non-ambulatory.

Physical plant is not consistent with the facility sketch received by Central Application Bureau (CAB).
The facility has two floors, and 22 rooms. The first floor has a lobby, receptionist carea, administrator’s office, activities room, resident rooms, kitchen and dining area. Signal System: Signal system in facility is individual resident pendent call buttons. Bedroom Residents: There shall be no more than two clients per bedrooms. bedrooms are designated resident bedrooms properly equipped with regulation guidelines of two beds, two chairs, and two night stands. Presently, 14 bedrooms are occupied by 2 clients and 6 bedroom by 1 client. Bedroom Staff: No bedrooms will be used for awake staff. Bathrooms: eight rooms have a shared half bath bathroom and 14 rooms have private half bathrooms. There are two visitor and staff bathrooms. The facility is equipped with two shower rooms, one shower room is currently being used as storage for the facility and not ready for residents use. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored where the house keeping supplies are kept. Smoke Detectors: There are hard wired smoke detectors throughout the build and in resident rooms, sprinkler system through the whole facility which are interconnected.

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SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ROSEMONT GARDENS
FACILITY NUMBER: 019201382
VISIT DATE: 10/31/2024
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LPAs observed the following:
Facility sketch is not contestant with the building
The resident rooms do not have adequate lighting
The resident bathroom floors appear to be dirty
There is one shower usable for 29 residents
water temperature is 123.6 degrees
Chemicals were observed unlocked in storage/shower room
there is not a compliance poster posted
rooms that have oxygen stored do not have signs posted
There is not an office space for administrator

Upon receipt of the proof of corrections for the items above by November 20, 2024, LPA Clancy-Czuleger will come back out for reinspection. and Component III.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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