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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200901
Report Date: 09/01/2022
Date Signed: 09/01/2022 04:45:35 PM

Document Has Been Signed on 09/01/2022 04:45 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:ROSE WATERS HOMEFACILITY NUMBER:
079200901
ADMINISTRATOR:BENDER, CHABAFACILITY TYPE:
740
ADDRESS:1719 MENDOCINO DRIVETELEPHONE:
(925) 270-3871
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 6DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rose Kamau, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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On 09/01/2022 at 3:00 pm, Licensing Program Analysts (LPAs) C. Fowler and P. Watson arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Rose Kamau and explained the purpose of the visit. Approximately 4:15 pm, Administrator Chaba Bender arrived.

Upon entry, LPAs observed screening station that contained hand sanitizer, masks and COVID signage. LPAs toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPAs observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters.

During record review, LPA observed visitors log and temperature logs for residents or staff. LPAs observed facility has a copy of Mitigation.

The following deficiencies were observed during the visit:

-At 3:05 pm , LPAs observed volunteers not associated to facility.
-At 3:11 pm, LPAs observed ant/roach/spider spray


The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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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Document Has Been Signed on 09/01/2022 04:45 PM - It Cannot Be Edited


Created By: Carol Fowler On 09/01/2022 at 04:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ROSE WATERS HOME
FACILITY NUMBER: 079200901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having volunteers that are not finger print cleared working at the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/02/2022
Plan of Correction
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Admistrator will associate volunteers to facility and send proof to CCLD by POC date
Type A
Section Cited
CCR
87309(1)(a)

(1) 87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Storage areas for poisons... shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having ant/roach/spider spray accessible to residents which poses an immediate health and safety risk do to persons in care
POC Due Date: 09/02/2022
Plan of Correction
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Administrator moved bug spray to a locked cabinet.
Deficiency cleared during visit.
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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
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