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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310303287
Report Date: 02/23/2022
Date Signed: 02/24/2022 08:54:59 AM

Document Has Been Signed on 02/24/2022 08:54 AM - 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ROSE GARDEN RESIDENTIAL CARE HOMEFACILITY NUMBER:
310303287
ADMINISTRATOR:ANDRADA, ROSALINDAFACILITY TYPE:
740
ADDRESS:12520 KILLARNEY WAYTELEPHONE:
(530) 823-8216
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 12CENSUS: 12DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jerry AndradaTIME COMPLETED:
04:00 PM
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LPA Tryon arrived at the facility on 2/23/2022 to perform an annual visit using the Infection Control Domain. Prior to the visit, LPA did a self-screening by taking temperature and reviewing possible symptoms. LPA wore a N-95 mask and used hand sanitizer. LPA met with Jerry Andrada and Tito Andrada Jr..

LPA toured the facility including common areas, kitchen, bedrooms, bathrooms, hallways, patio, yard.

LPA reviewed the infection control domain with the staff.

The facility appears to be in substantial compliance at this time.

Exit interview conducted
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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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