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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201057
Report Date: 05/13/2025
Date Signed: 05/13/2025 03:39:40 PM

Document Has Been Signed on 05/13/2025 03:39 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:
05/13/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Marie Etienne, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On 5/13/2025, at 10:10am, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson conducted an unannounced Case Management health and safety check. LPA met with Marie Etienne, Caregiver, explained the purpose of the visit.

LPA received called on 5/12/2025, from Licensee, stating the property and business has been sold. New potential owners (S2 and S3) arrived at 11:00am. Facility is licensed for six (6) ambulatory residents only.

LPAs observed the following deficiencies:
  • At 10:15am, LPAs observed S1 was not fingerprinted or associated.
  • At 10:25am, LPAs observed facility did not have a qualified administrator.
  • At 10:30am, LPAs observed garage door unlocked with bleach, gallon of primer, gallon of paint, Fabuloso, laundry detergent, and Clorox disinfectant accessible.
  • At 10:40am, LPAs observed facility did not have a sufficient amount of linen. LPAs observed 2 mattress pads,
  • At 11:00am, LPAs observed S2 is not associated and S3 is not fingerprinted or associated to the facility.

Continued on LIC809C.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2025
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 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/13/2025
NARRATIVE
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Continued from LIC809.
  • At 11:15am, LPAs observed medication for all residents pre-poured for the week.
  • At 11:15am, LPAs observed there was not any list of medication for the residents.
  • At 11:20am, LPAs observed facility did not have an ambulatory fire clearance.
  • At 11:50pm, LPAs observed facility did not have any liability insurance for the facility.
  • At 03:00pm, LPAs observed R1 has a restricted health condition.


*An immediate civil penalty in the amount of $2700.00 will be assessed on today's date*
$400 x 1 for 87355(d) for fingerprint
$400 x 2 = $800 for 87355(e) for association
$1000 x1 for 87202(a)(1) for fire clearance
$250 x 1 for 87405(a) repeat for administrator qualifications
$250 x 1 for 87465(h)(6) repeat for medications not in original container

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 conduct. A copy of the appeal rights, LIC421BG, LIC421IM, LIC421FC, and the report provided.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2025 03:39 PM - It Cannot Be Edited


Created By: Laura Hall On 05/13/2025 at 12:03 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: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2025
Section Cited
CCR
87355(d)

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(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement was not met as evidence by:
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Licensee agreed to get S1 fingerprinted and submit copy of document to CCLD by POC date.
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Based on record review and interview the Licensee did not comply with the section cited above in having S1 fingerprinted before being employed at the facility, which poses a potential health and safety risk to persons in care.
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Type A
05/14/2025
Section Cited
CCR87355(e)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement was not met as evidence by:
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Licensee submtited LIC9182 and a copy of S2 and S3 identification to associate them to the facility during visit. Deficiency cleared during visit.
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Based on observation and interview the Licensee did not comply with the section cited above in having S2 and S3 associated to the facility, which poses an potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2025 03:39 PM - It Cannot Be Edited


Created By: Laura Hall On 05/13/2025 at 12:19 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: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2025
Section Cited
CCR
87309(a)

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(a... the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances... and other similar items which could pose a danger to residents are in locked storage and are not left unattended... This requirement was not met as evidence by:
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Licensee agreed to lock garage that contained laundry detergent, Clorox, paint and other items, and submit photo to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above by not having disinfectants, laundry detergents, paints accessible to residents, which poses an immediate health and safety risk to persons in care.
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Type A
05/14/2025
Section Cited
CCR87202(a)(1)

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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department... Prior to accepting or retaining any of the following types of persons...
(1) Non ambulatory persons.
This requirement was not met as evidence by:
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Licensee agreed to submit an LIC200 and updated copy of the facility sketch to CCLD by POC date.
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Based on observation and record review the Licensee did not comply with the section cited above in having proper fire clearance for non ambulatory residents, which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2025 03:39 PM - It Cannot Be Edited


Created By: Laura Hall On 05/13/2025 at 12:39 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: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2025
Section Cited
CCR
87307(a)(3)(c)

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(a) ... The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance... shall be ...readily available to each resident. (C) Clean linen... towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often... This requirement was not met as evidence by:
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License agreed to purchase bedding and linen and submit a photo to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in having a sufficient amount of bedding and towels available for residents, which poses a potential health and safety risk to persons in care.
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Type B
05/20/2025
Section Cited
HSC1569.605

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... all residential care facilities for the elderly... shall maintain liability insurance covering injury to residents and guests in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement was not met as evidence by:

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Licensee agreed to purchase liability insurance and submit a copy to CCLD by POC date.
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Based on record review and interview the Licensee did not comply with the section above in having liability insurance for the facility which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2025 03:39 PM - It Cannot Be Edited


Created By: Laura Hall On 05/13/2025 at 01:05 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: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2025
Section Cited
CCR
87405(a)

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(a) All facilities shall have a qualified and currently certified administrator.... The administrator shall... on the premises a sufficient number of hours... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications.... This requirement was not met as evidence by:
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Licensee agreed to hire a qualified administrator and submit all documentation to CCLD by POC date.
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Based on observation and interview the Licensee did not comply with the section cited above in having an administrator
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Type B
05/20/2025
Section Cited
HSC1569.191(a)(1)

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(a) Notwithstanding Section 1569.19, in the event of a sale of a licensed facility where the sale will result in a new license being issued, the sale and transfer of property and business shall be subject to both of the following:
(1) The licensee shall provide written notice to the department and to each resident or his or her legal representative of the licensee's intent to sell the facility at least 30 days prior to the transfer of the property or business, or at the time that a bona fide offer is made, whichever period is longer.
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Licensee agreed to submit letter given to resident or residents representative to CCLD by POC date.
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This requirement was not met as evidence by: Based on interview the Licensee did not comply with the section cited above in notifying CCLD and representatives of sale of business, which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2025 03:39 PM - It Cannot Be Edited


Created By: Laura Hall On 05/13/2025 at 01:24 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: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2025
Section Cited
CCR
87465(h)(5)

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(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidence by:
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Licensee agreed to review regulation 87465 and submit self-certification that the facility will abide by regulation going forward to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited in maintaining medication in it's original container, which poses a potential health and safety risk to persons in care.
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Type B
05/20/2025
Section Cited
CCR87465(h)(6)

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(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement was not met as evidence by:
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Licensee agreed to obtain records for medication for all 3 residents and submit records to CCLD by POC date.
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Based on observation and record review the Licensee did not comply with the section cited above in having records of medication for all 3 residents, which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2025 03:39 PM - It Cannot Be Edited


Created By: Laura Hall On 05/13/2025 at 03:01 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: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2025
Section Cited
CCR
87623(b)

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(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: This requirement was not met as evidence by:
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Licensee agreed to obtain care plan from home health for R1 and submit plan to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in having documentation for R1's catheter/home health which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
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