<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200904
Report Date: 09/13/2022
Date Signed: 09/13/2022 01:22:56 PM

Document Has Been Signed on 09/13/2022 01:22 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: 6DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Care Staff, Elisa EmpigTIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/13/2022 at 12:05 PM Licensing Program Analysts (LPAs) L. Holmes and M. Malik conducted an unannounced annual infection control inspection. LPAs met with Elisa Empig, co-administrator, and informed the purpose of visit.

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 11, 2022. 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 105.3 degrees Fahrenheit.



.......continued on 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 09/13/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
...Continued from LIC809

The following forms are to be updated:
-LIC500 Personnel Report (Received)
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s) (Reviewed and to be posted)

Exit interview conducted and a copy of this report provided to Elisa Empig.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2