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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201057
Report Date: 10/01/2024
Date Signed: 10/01/2024 02:19:55 PM

Document Has Been Signed on 10/01/2024 02:19 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:
10/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Rizalina Hutchko, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:30 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 10/1/2024, Licensing Program Analysts (LPAs), L. Hall and D. Doidge arrived unannounced to conduct a case management visit. LPAs met with Caregiver, Rizalina Hutchko. House manager, Arvin Franco, arrived at 12:10pm, and LPAs explained the purpose of the visit.

Case management visit was for a follow-up for an annual inspection completed on 8/20/2024. During visit LPAs reviewed the three (3) resident records and five (5). All resident and staff records are incomplete. LPAs toured facility and observed three (3) residents. During record review LPAs observed two (2) of three (3) residents are non-ambulatory. Facility fire clearance for the facility is for six (6) ambulatory residents only.

The following deficiencies were observed:
  • At 11:45am, LPAs observed facility did not have supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises
  • At 12:40pm, LPAs observed during record review that the facility have two (2) non-ambulatory residents but does not have a non-ambulatory fire clearance.


Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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 3
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: 10/01/2024
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.

*An immediate civil penalty will be assessed on today's date for $500.00 for fire clearance*

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights, LIC421M, and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/01/2024 02:19 PM - It Cannot Be Edited


Created By: Laura Hall On 10/01/2024 at 01:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ROSE OF SHARON HEALTHCARE
FACILITY NUMBER: 079201057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2024
Section Cited
CCR
87202(a)(1)

1
2
3
4
5
6
7
87202 (a) All facilities shall maintain a fire clearance approved by the city, county... fire protection services... Prior to accepting... persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance...(1) Nonambulatory persons. This requirement was not met as evidence by:
1
2
3
4
5
6
7
House manager agreed to sumbit a LIC200 and updated facility sketch to CCLD by POC date.
8
9
10
11
12
13
14
Based on observation and record review the Licensee did not comply with the section cited above in have an approved fire clearance for non-ambulatory residents, which poses a potential health and safety risk for persons in care.
8
9
10
11
12
13
14
*An immediate $500 civil penalty fire fire clearance*
Type B
10/04/2024
Section Cited
CCR87555(26

1
2
3
4
5
6
7
87555 General Food Service Requirements (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidence by:
1
2
3
4
5
6
7
House Manager agreed to purchase food and submit photos of food and receipts to CCLD by POC date.
8
9
10
11
12
13
14
Based on observation the Licensee did not comply with the section cited above in having 7 day supply of non-perishable and 2-day perishable foods for residents, which poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3