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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201185
Report Date: 09/20/2022
Date Signed: 09/20/2022 03:25:12 PM

Document Has Been Signed on 09/20/2022 03:25 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:ROSEWOOD RESIDENCE LLCFACILITY NUMBER:
079201185
ADMINISTRATOR:HERBERT, HELENFACILITY TYPE:
740
ADDRESS:7100 MANILA AVENUETELEPHONE:
(510) 778-9084
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY: 6CENSUS: 5DATE:
09/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Helen Grace Herbert, Licensee and Araceli Emerick, Co-AdministratorTIME COMPLETED:
03:00 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 09/20/22 at 01:15 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a Pre-Licensing Inspection for a CHOW. LPA was greeted by one Care Staff upon entry and explained the purpose of the visit. Helen Grace Herbert, Licensee and Araceli Emerick, Co-Administrator (Co-ADM) arrived about 5 minutes later. The facility's fire clearance was approved for all six (6) residents of which five (5) may be non-ambulatory and one (1) bedridden.

LPA toured facility with Licensee and Co-ADM including, but not limited to five (5) residents' bedrooms, two (2) bathrooms, kitchen, common areas, and backyard. Bedrooms and living rooms were equipped with the proper furniture. The Bathrooms were equipped soap, paper towels and covered garbage cans. Medication and sharps are stored and locked by a combination lock. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. Lighting is sufficient throughout the facility. The room temperature was maintained at 76 degree F and hot water temperature was maintained at 117.8 degree F. First-aid kit was observed complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 08/15/2022. Component III reviewed and completed with Licensee and Co-ADM.

During record review, LPA reviewed five (5) residents and ten (10) staff records; the records were current and maintained.

LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided to Helen Grace Herbert, Licensee and Araceli Emerick, Co-Administrator.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2022
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 1