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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200979
Report Date: 08/11/2021
Date Signed: 08/11/2021 11:28:15 AM

Document Has Been Signed on 08/11/2021 11:28 AM - 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:
079200979
ADMINISTRATOR:EMERICK, ARACELIFACILITY TYPE:
740
ADDRESS:5311 GARVIN AVENUETELEPHONE:
(510) 237-5769
CITY:RICHMONDSTATE: CAZIP CODE:
94805
CAPACITY: 6CENSUS: 6DATE:
08/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Araceli Emerick, AdministratorTIME COMPLETED:
11:40 AM
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On 8/11/2021 at 9:24AM, Licensing Program Analysts (LPAs) G. Luk and L. Holmes arrived unannounced to conduct an Infection Control Inspection. LPAs met with staff, Shierly Flores and explained the purpose of the visit. Administrator, Araceli Emerick arrived 15 minutes later.

Upon entry, LPA's temperatures were checked. LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, and outdoor areas. LPAs observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPAs observed visitors log and temperature logs for both residents and staff. Facility has logs for staff COVID-19 surveillance testing. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed PPEs, food, and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 9:45AM, LPAs observed unlocked knives and cleaning supplies in the kitchen. Unlocked gardening tools were observed in the backyard. Staff locked up knives, cleaning supplies, and gardening tools during inspection.

-At 9:50AM, LPAs observed unlocked vitamins in the kitchen. Staff locked up the vitamins.

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

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2021
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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Document Has Been Signed on 08/11/2021 11:28 AM - It Cannot Be Edited


Created By: Grace Luk On 08/11/2021 at 11:09 AM
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: 079200979

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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.

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 unlocked knives, cleaning supplies, and gardening tools which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/12/2021
Plan of Correction
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Staff locked up the knives, cleaning supplies, and gardening tools during inspection.

Deficiency cleared during inspection.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 unlocked vitamins which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/12/2021
Plan of Correction
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Staff locked up the vitamins during inspection.

Deficiency cleared during inspection.
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:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021


LIC809 (FAS) - (06/04)
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