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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200979
Report Date: 08/26/2024
Date Signed: 08/26/2024 04:27:39 PM

Document Has Been Signed on 08/26/2024 04:27 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:
079200979
ADMINISTRATOR/
DIRECTOR:		EMERICK, ARACELIFACILITY TYPE:
740
ADDRESS:5311 GARVIN AVENUETELEPHONE:
(510) 237-5769
CITY:RICHMONDSTATE: CAZIP CODE:
94805
CAPACITY: 6CENSUS: 6DATE:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH: Elisa Empig, Designated Responsible Party TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 08/26/2024 around 02:00 PM, LPA L Holmes arrived at the facility. Care Staff telephone and Elisa Empig, Designated Responsible Party (S1) and explained the purpose of the visit. S1 arrived about 15 minutes.

LPA and S1 toured the facilely including but not limited to the common areas, dining room, bathrooms, kitchen, bedrooms. The facility consists six (6) residents. All but one was sleeping. Outdoor and indoor passageways were free of obstruction. There were not any bodies of water present. A comfortable temperature was maintained at 71 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. The hot water temperature in the shared restroom was measured at 114.4 degrees (F). The shared restrooms had paper towels, soap and garbage cans; all areas were safe and sanitary. PPE, sanitizer, and paper goods remain sufficient. There is a 2-day supply of perishable foods and a 7-day supply of non-perishable foods.

...continued on LIC9099C.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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: 079200979
VISIT DATE: 08/26/2024
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...continued from LIC9099.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full and serviced 03/13/24. Emergency Disaster Plan is updated. Safety drills are rotational between quarterly, last on 06/14/24. LPA reviewed three (3) staff files, and six (6) resident files.

The following forms are to be updated and submitted to CCLD 09/02/24:
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate
-Resident Roster
-Liability Insurance

Exit interview conducted and a copy of this report provided to Care Staff Cecelia Del Moral
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
LIC809 (FAS) - (06/04)
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