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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201046
Report Date: 05/07/2021
Date Signed: 05/07/2021 03:57:17 PM

Document Has Been Signed on 05/07/2021 03:57 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:ROSE COTTAGE RCFEFACILITY NUMBER:
079201046
ADMINISTRATOR:BOYKIN, MYNETTEFACILITY TYPE:
740
ADDRESS:1972 JEANETTE DRTELEPHONE:
(925) 798-7826
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 6CENSUS: 0DATE:
05/07/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mynette Boykin, Applicant/AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Praveen Singh conducted a Pre-licensing Inspection on today's date. Due to the Governor's present shelter in place order, this inspection was completed via video-conference with Applicant/Administrator Mynette Boykin.

This facility currently has six residents and is operating under license number 079200531. This Pre-Licensing is relative to facility's change of ownership application. The facility has six (6) private resident bedrooms and one (1) staff room. LPA toured facility inside and out, including bedrooms, bathrooms, living rooms, kitchen, dining area, and outside areas. LPA observed that bathrooms contained grab bars and non-skid mats. LPA observed a sufficient supply of extra linens and a locked cabinet for centrally stored medications and resident/staff files. LPA observed a sufficient supply of dishes and utensils. LPA observed a sufficient supply of perishable and non-perishable foods. LPA observed Large Ombudsman and Community Care Licensing's If You See Something... posters were posted on the wall. LPA observed auditory signals, fire extinguishers, first aid kits, smoke alarms, and carbon monoxide detectors. Fire extinguishers were last serviced in February 2021. There were safety night lights in the hallway and in the resident bedrooms. Exits and passageways were free of obstruction.

LPA observed that facility is not yet ready to be licensed. During today's inspection, a discrepancy was discovered regarding the facility's Fire Clearance. Once resolved, LPA will conduct a final Pre-Licensing inspection of the facility.

See LIC809 (Case Management Report) dated 5/7/2021, for Comp III Review conducted today.

Exit interview conducted and a copy of the report provided via email.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Praveen Singh
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2021
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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