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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920068
Report Date: 02/26/2025
Date Signed: 02/26/2025 05:19:52 PM

Document Has Been Signed on 02/26/2025 05:19 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ROSE BRIDGE VILLAFACILITY NUMBER:
315920068
ADMINISTRATOR/
DIRECTOR:		BALJEET SINGHFACILITY TYPE:
740
ADDRESS:6709 ROSE BRIDGE DRIVETELEPHONE:
(916) 474-5620
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 4DATE:
02/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on February 26, 2025 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator was unavailable to be present- spoke with LPA by phone.
LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA found the water temp to be 120'F in resident bathroom. Advised caution and monitoring. LPA advised that the current Administrator's certificate be posted.
LPA reviewed two (2 ) resident and one ( 1) staff files. Two resident files were not present at the facility (R2 and R4). Licensee to submit the following for R2 and R4: Physician's assessment, pre-appraisal and appraisal/ needs and services plan.
S1 was found to have current 1sr aid but not CPR. S1 is working alone and CPR is required.
LPA requested the following documents to update the facility file: LIC 500, liability insurance certificate and updated plan of operations for new dementia regulations. LPS provided Dementia Care flier and advised review of PIV24- 09-ASC.

As a result of this inspection, the following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
Exit interview conducted with caregiver/ designee and copy of report and appeal rights left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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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Document Has Been Signed on 02/26/2025 05:19 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 02/26/2025 at 04:46 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSE BRIDGE VILLA
FACILITY NUMBER: 315920068

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in three (3) of four (4) - One present and 2 absent- records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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Licensee will submit a completed Appraisal for R1 which meets new regulations, as well as those requested for R2 and R4 by the POC date of 3/19/25
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
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