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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290817
Report Date: 07/12/2022
Date Signed: 07/12/2022 12:54:43 PM

Document Has Been Signed on 07/12/2022 12:54 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ROSEWOOD HOMEFACILITY NUMBER:
191290817
ADMINISTRATOR:ROSEMARIE F. DECENARIOFACILITY TYPE:
740
ADDRESS:9645 FULLBRIGHT AVENUETELEPHONE:
(818) 993-9719
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 5DATE:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Rosemarie DecenarioTIME COMPLETED:
01:05 PM
NARRATIVE
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On 07/12/22 at 11:30 a.m Licensing Program Analyst (LPA) Joscelyn Martinez conducted an unannounced annual inspection. Upon arrival LPA met with staff and later met with Administrator Rosemarie Decenario. The purpose of the visit was explained.

At 11: 35 a.m. LPA conducted a physical tour of the facility. Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Upon entrance, staff took LPA’s temperature and was asked to sign-in the visitor’s log. Facility has sufficient PPE supplies for more than 30 days. Food Inspection: LPA Martinez observed there was sufficient stock of one-week non-perishable foods and two-day perishable foods. Medications are centrally stored in a locked kitchen drawer. Kitchen is sanitary and free of pests. Smoke detectors/carbon monoxide are located throughout the facility. Carbon monoxide detector was tested at 11:46 a.m and is functional. Smoke detectors were tested at 11:57 a.m and are functional. Fire extinguisher has a purchase date of 05/22/2022. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 77.0 F. Chemicals are kept in a locked closet located in the hallway. Residents Rooms: There are (5) bedrooms of which four (4) are designated for resident use. Facility has one live in staff. Laundry area is accessible through staff room. All the five (5) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. Bathrooms: There are two (2) bathrooms in the facility. LPA observed all bathrooms to have grab bars and non-skid mats. The hot water was tested and measured at 130.0 F. Administrator lowered the water temperature at the time of the visit.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROSEWOOD HOME
FACILITY NUMBER: 191290817
VISIT DATE: 07/12/2022
NARRATIVE
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Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water. Facility does not have a garage.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/12/2022 12:54 PM - It Cannot Be Edited


Created By: Joscelyn Martinez On 07/12/2022 at 12:23 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSEWOOD HOME
FACILITY NUMBER: 191290817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2022
Section Cited

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87303(e)(2) Maintenance and Operation:
Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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This requirement is not met as evidenced by:
Based on observation, the licensee did not comply with the section cited above in ensuring the water temperature was within regulation which poses an immediate health, safety or personal rights 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.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022


LIC809 (FAS) - (06/04)
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