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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600148
Report Date: 06/20/2022
Date Signed: 06/20/2022 12:47:00 PM

Document Has Been Signed on 06/20/2022 12:47 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:ROSEGATEFACILITY NUMBER:
015600148
ADMINISTRATOR:LEUNG, BELINDAFACILITY TYPE:
740
ADDRESS:1345 CLARKE STREETTELEPHONE:
(510) 483-0150
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 40CENSUS: 15DATE:
06/20/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Michael Fombang, Assistant Administrator Jefferey Tong, Backup Administrator TIME COMPLETED:
11:30 AM
NARRATIVE
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On 6/20/2022 starting at 10:45 AM, Licensing Program Analyst (LPA) L. Ibo conducted a health and safety check as a result of department receiving a priority 1 complaint. LPA met with Michael Fombang, assistant administrator and Jefferey Tong, back up administrator. Administrator is currently not available.

During the health and safety check, LPA toured the building with Michael F. including but not limited to common areas, bathrooms, bedrooms and outdoor area. LPA observed smoke detectors and carbon monoxide detector throughout facility.

LPA observed the following:

S1 not fingerprint cleared and working at the facility.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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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Document Has Been Signed on 06/20/2022 12:47 PM - It Cannot Be Edited


Created By: Leslie Ibo On 06/20/2022 at 12:11 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ROSEGATE
FACILITY NUMBER: 015600148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2022
Section Cited
CCR
87355(e)(1)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department
This requirement is not met as evidenced by:
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LPA advised that S1 are not allowed back to the facility until they obtain fingerprint clearance. Administrator shall ensure that all staff have been hired and have obtained a criminal record clearance and are associated to the facility. Administrator agreed to submit a copy of fingerprint clearance to CCL by POC date.

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Based on LPA observation, the licensee did not comply with the section cited above, LPA observed S1 working at the facility without obtaining fingerprint clearances, which poses an immediate health, safety or personal rights risk to persons in care.
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CIVIL PENALTY ASSESSED: $500.00

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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022


LIC809 (FAS) - (06/04)
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