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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600148
Report Date: 11/25/2024
Date Signed: 11/25/2024 12:01:01 PM

Document Has Been Signed on 11/25/2024 12:01 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ROSEGATEFACILITY NUMBER:
015600148
ADMINISTRATOR/
DIRECTOR:		LEUNG, BELINDAFACILITY TYPE:
740
ADDRESS:1345 CLARKE STREETTELEPHONE:
(510) 483-0150
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 40TOTAL ENROLLED CHILDREN: 0CENSUS: 29DATE:
11/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH: Jeffrey Tong, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 11/25/2024 at 9:00 AM, Licensing Program Analysts (LPAs), Patricia Manalo and Jill Clancy-Czuleger, arrived to do a Case Management visit. LPA met with Assistant Administrator, Jeffrey Tong, and explained the reason for the visit.

While LPAs was at the facility for another visit, LPAs observed the following deficiency:

At 9:00 AM, LPAs was informed that there are nine (9) residents that are COVID-19 positive. At around 10:00 AM, while touring the facility, LPAs found that the facility did not report the outbreak to Local Public Health.

At 10:30 AM, while touring the facility for a change of ownership inspection, LPAs observed that there are four bathrooms total in the facility. Two are on the second floor of which one is in a private room, and the other is only accessible to ambulatory residents. The other two are on the first floor and only one is accessible to non-ambulatory residents. The facility currently has 29 residents, 8 are ambulatory and 21 are non-ambulatory which means there is only one bathroom for 21 non-ambulatory residents.


The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
Yvonne Flores-LariosTELEPHONE: (510) 286-4201
Patricia ManaloTELEPHONE: (916) 432-7785
DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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 2
Document Has Been Signed on 11/25/2024 12:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ROSEGATE
FACILITY NUMBER: 015600148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
(2)Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, ... shall be reported within 24 hours either by telephone or facsimile to the licensing agency...This requirement is not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 11/26/2024
Plan of Correction
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Administrator agrees to review COVID-19 Infection Control training and send a letter to CCLD for self-certification. Administrator agrees to contact Local Public Health for reccomendations.
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.
Yvonne Flores-LariosTELEPHONE: (510) 286-4201
Patricia ManaloTELEPHONE: (916) 432-7785

DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024

LIC809 (FAS) - (06/04)
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