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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200904
Report Date: 12/20/2023
Date Signed: 12/20/2023 06:31:01 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/20/2023 06:31 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:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Joevy Madamba, CaregiverTIME COMPLETED:
06:45 PM
NARRATIVE
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On 12/20/2023 at 4:00pm, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson, conducted an unannounced 1-Year Required inspection. LPAs met with Joevy Madamba, Caregiver and explained the purpose of the visit. Administrator, Helen Herbert, arrived at 4:19pm. The facility’s fire clearance was approved for four (4) non-ambulatory and 2 bedridden residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of five (5) total bedrooms one (1) is occupied by staff, and one (1) bathroom. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 115.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors/ carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 4/27/2023. Emergency Disaster Plan was last posted on 2/10/2023. First aid kit was observed to be complete.

Continued on LIC809.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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: 12/20/2023
NARRATIVE
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Continued from LIC809.

Four (5) staff records were reviewed, and all staff have criminal record clearance. All six (6) resident records were reviewed and one (1) did not have current physician's reports.

LPA requested the following documents to be submitted to CCLD by 12/29/2023.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • Resident roster
  • Liability Insurance

LPA observed the following deficiencies:
  • At 4;35pm, LPAs observed during record review R1 did not have a current physican's report.
  • At 5:25pm, LPA observed portable heaters in three (3) residents bedrooms.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/20/2023 06:31 PM - It Cannot Be Edited


Created By: Laura Hall On 12/20/2023 at 06:01 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: ROSEWOOD RESIDENCE, LLC
FACILITY NUMBER: 079200904

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
87307(d)(7)

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87307 Personal Accommodations and Services(d) The following space and safety provisions shall apply to all facilities:(7) Fireplaces and open-faced heaters shall be adequately screened. This requirement was not met as evidence by:
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Administrator immediately removed heaters out of the bedrooms. Deficiency cleared during visit.
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Based on observation the Licnesee did not comply with the section cited above in having portable heaters in 3 bedrooms, which poses a potential health and safety risk for persons in care.
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Type B
01/12/2024
Section Cited
CCR87705(c)(5)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458.... This requirement was not met as evidence by:
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Administrator agreed to obtain a current physician's report for R1 and R2 and submit copy to CCLD by POC date.
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Based on record review the Licensee did not comply with the section cited above in have physician reports for 2 residents which poses a potential health and safety risk for persons in care.
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023


LIC809 (FAS) - (06/04)
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