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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200904
Report Date: 11/30/2021
Date Signed: 11/30/2021 05:13:39 PM

Document Has Been Signed on 11/30/2021 05:13 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:ROSEWOOD RESIDENCE, LLCFACILITY NUMBER:
079200904
ADMINISTRATOR:HERBERT, HELEN GRACEFACILITY TYPE:
740
ADDRESS:869 HUMBOLDT STREETTELEPHONE:
(510) 215-1400
CITY:RICHMONDSTATE: CAZIP CODE:
94805
CAPACITY: 6CENSUS: 4DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Elisa Empig/Co-administratorTIME COMPLETED:
05:20 PM
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Licensing Program Analysts (LPAs) Alicia Delmundo and Lisha Holmes conducted an unannounced infection control annual inspection. LPAs met with Elisa Empig, co-administrator, and informed the purpose of visit. LPA also met with staff, Carmelita Bahilot and Conrado Empig.

Facility has a completed COVID-19 mitigation plan and submitted to Community Care Licensing (CCL).

LPAs inspected the facility inside and out with Elisa Empig. LPAs observed screening station located near the front entrance with visitor's log, hand sanitizer and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff and visitors. Residents are screened for COVID-19 symptoms and temperature checked daily. LPAs observed COVID-19 signages posted all through out the facility. Trash bins were observed with step-on operated lids.

Medications are centrally stored in the a locked cabinet. Centrally stored PPEs inspected. There were at least 7 days of nonperishable and 2 days of perishable food supplies.

Fire extinguisher was observed fully charge and tag showed serviced January 12, 2021. Smoke and carbon monoxide detectors were operational. First aid kit inspected and observed complete with manual. Hot water temperature in the common bathroom was tested and measured at 108.5 degrees Fahrenheit.



.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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: ROSEWOOD RESIDENCE, LLC
FACILITY NUMBER: 079200904
VISIT DATE: 11/30/2021
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LPAs observed the following:
1. No visitor's poster on the entrance door.
2. Disposable gowns not sufficient for 30 days for 6 staff.

LPAs verified and Elisa Empig stated staff are not fit tested for N95 respirator.

LPAs requested for copies of the following updated documents to be submitted to CCL by December 14, 2021:
1. LIC500 Personnel Report
2. LIC308 Designation of Facility Responsibility
3. LIC610E Emergency Disaster Plan
4. Proof of $3M liability insurance coverage

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
LIC809 (FAS) - (06/04)
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