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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201057
Report Date: 06/23/2021
Date Signed: 06/23/2021 01:25:27 PM

Document Has Been Signed on 06/23/2021 01:25 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 OF SHARON HEALTHCAREFACILITY NUMBER:
079201057
ADMINISTRATOR:AKOGNON, OJOFACILITY TYPE:
740
ADDRESS:1 KINGSWOOD DRIVETELEPHONE:
(925) 427-2782
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 0DATE:
06/23/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Ojo Akognon, AdministratorTIME COMPLETED:
12:45 PM
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On 06/23/2021 at 11:05am, Licensing Program Analyst (LPA) L. Hall conducted an announced pre-licensing inspection and met with Ojo Akognon, Administrator. Licensee. Facility has a fire clearance for six (6) ambulatory residents.

LPA toured the facility including but not limited to residents bedrooms, bathrooms, dining room, common living area, kitchen, garage, and backyard. There is sufficient lighting around the facility. Residents rooms are equipped with the proper furniture, lighting, and have proper bedding and linens. Bathrooms were equipped with grab bars and non-skid mats. All toxins and sharp objects are locked. Passageways and hallways are free of obstruction. Fire extinguisher was last serviced on 2/2021. Smoke detectors/ Carbon Monoxide detector were in operating condition during visit. Hot water temperature is measured at 117.1 degrees Fahrenheit. Emergency Disaster Plan was last posted on 06/23/2021. First aid kit was observed to be complete. The facility has a supply of 2-day perishable, and 7-day nonperishable foods for the residents.

Prior to licensure, the following shall be corrected and faxed to CCLD by 06//30/2021.

-A photo of backyard free of debris.
-A photo of the door knob leading to the garage switched.
-A photo of the shed with a lock.
-A photo of both refrigerators, one in the garage and one kitchen cleaned.
-A photo of water temperature while.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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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