<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201057
Report Date: 08/29/2024
Date Signed: 08/29/2024 04:10:40 PM

Document Has Been Signed on 08/29/2024 04:10 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/
DIRECTOR:		AKOGNON, OJOFACILITY TYPE:
740
ADDRESS:1 KINGSWOOD DRIVETELEPHONE:
(925) 267-2288
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 3DATE:
08/29/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Eva Bode, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/29/2024, at 1:35PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a proof of correction (POC) visit. LPA met with Eva Bode, Caregiver, and explained the purpose of the visit.

LPA conducted an annual inspection on 8/20/2024 and cited for the following deficiencies that has not been corrected.

  • 87555(26), LPA observed facility does not have a 7-day supply of non -perishables and 2-day of perishables foods.
  • 87405(a) LPA observed facility have not implemented a plan to hire or recertify an Administrator.
  • 87203 - LPA observed fire extinguisher has not been services and facility has not purchased a new fire extinguisher.
  • 87211(a)(1) - LPA observed facility did not report incident for R1.
  • 87307(d)(6) - LPA observed couch, loveseat, freezer, shovel, and rake in backyard.
  • 87506(d) - LPA observed resident records still not at facility available for review.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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: ROSE OF SHARON HEALTHCARE
FACILITY NUMBER: 079201057
VISIT DATE: 08/29/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809.
  • 87412(f) - LPA observed staff records still not at facility available for review.
  • 87705(l)(8) - LPA observed facility still have not conducted a fire drill.
  • 87465(8) - LPA observed facility has not bought a first aid kit.

  • 87411(a) - LPA observed facility does not have sufficient staffing to meet residents needs.

  • 87465(h)(6) - LPA observed records for medication is not accurate.


LPA conducted an annual inspection on 8/20/2024, and cited for the following deficiency have been corrected.
  • 87705(f)(2) - Caregiver removed medication next to R1's bed and locked medication in cabinet.
  • Each uncorrected deficiency is $100.00 x 2 = $2200.00.

Civil Penalties in the total amount of $2200.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiencies are corrected.

Exit interview conducted. A copy of this report, LIC421FC, and appeal rights provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2