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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201057
Report Date: 09/08/2022
Date Signed: 09/08/2022 02:18:46 PM

Document Has Been Signed on 09/08/2022 02:18 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) 267-2288
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 0DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:James Villaflores, StaffTIME COMPLETED:
02:25 PM
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On 9/8/2022 at 12:30PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. At 1:20PM, James Villaflores, Staff arrived and LPA explained the purpose of the visit. There are not any residents residing at facility at this time.

Upon entry, LPA's temperature was not checked. LPA observed screening station. There were not any COVID signs posted on front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA did not observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hot water temperature in the shared clients’ bathroom was measured at 120.2 degrees Fahrenheit. Fire extinguisher last serviced on 2/22/2022.

During record review, LPA observed visitors sign-in log.

LPA request the following documents to be submitted to CCLD by 9/15/2022.
  • LIC 9182 Infection Control Plan
  • A copy of Administrator Certificate

No deficiencies cited during this visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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