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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600148
Report Date: 10/31/2024
Date Signed: 10/31/2024 01:11:46 PM

Document Has Been Signed on 10/31/2024 01:11 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/
DIRECTOR:		LEUNG, BELINDAFACILITY TYPE:
740
ADDRESS:1345 CLARKE STREETTELEPHONE:
(510) 483-0150
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 40TOTAL ENROLLED CHILDREN: 0CENSUS: 29DATE:
10/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Jeffery Tong, Backup Administrator TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 10/31/2024 at 8:45AM, Licensing Program Analyst (LPA) J Clancy-Czuleger and P Manalo while at the facility for a pre-licensing observed the following deficiencies:

water temperature is 123.6 degrees
Chemicals were observed unlocked in storage/shower room
there is not a compliance poster posted
rooms that have oxygen stored do not have signs posted
residents do not have updated needs and services plans
residents with dementia do not have updated physicians reports

Deficiency is cited from Title 22 California Code of Regulation (see 809D). Failure to submit proof of correction and any repeat violation within twelve-month period may result in additional civil penalties.


Exit interview conducted. Appeal Rights, and copy of this report provided via e-mail.
Harpreet HumpalTELEPHONE: (510) 285-3928
Jill Clancy-CzulegerTELEPHONE: 510-286-4201
DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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 10/31/2024 01:11 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ROSEGATE
FACILITY NUMBER: 015600148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2024
Section Cited
CCR
87303(e)(2)

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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).This requirement is not met as evidenced by:
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The facility agrees to adjust the water temperature to be no less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Proof of correction will be sent to CCLD by POC date
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Based on observation, the licensee did not comply with the section cited above by having the water temperature mesured at 123.6 degrees which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
11/04/2024
Section Cited
CCR87309(a)

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(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement is not met as evidenced by:
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The facility agrees to relocate the cleaning supplies to a locked location. Proof of correction will be sent to CCLD by POC date
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Based on observation, the licensee did not comply with the section cited above by having chemicals left in unlocked shower/storage room 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/31/2024 01:11 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ROSEGATE
FACILITY NUMBER: 015600148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2024
Section Cited
CCR
87468(c)(2)(A)

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Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) The poster that is posted shall be 20" x 26" in size and be posted in the main entryway of the facility. This requirement is not met as evidenced by:
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The facility agrees to post PUB 475 in size 20" X 26" in the main entryway of the facility. Proof of correction will be sent to CCLD by POC date.
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Based on observation, the licensee did not comply with the section cited above by not having PUB 475 which poses a potential health, safety or personal rights risk to persons in care.
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Type B
11/11/2024
Section Cited
CCR87618(b)(3)(B)

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(b) ... the licensee shall be responsible for the following:(3) Ensuring that the use of oxygen equipment meets the following requirements:
(B)"No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
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The facility agrees to post signs at the rooms where oxygen is stored. Proof of correction will be sent to CCLD by POC date.
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Based on observation, the licensee did not comply with the section cited above by not having signs outside of resident rooms that had Oxygen stored which poses a potential 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/31/2024 01:11 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ROSEGATE
FACILITY NUMBER: 015600148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2024
Section Cited
CCR
87705(c)(5)

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(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.This requirement is not met as evidenced by:
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The facility agrees to review all resident records and schedule appointments for all residents with dementia who need updated physicans reports. Proof of correction will be sent to CCLD by POC date.
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Based on records review, the licensee did not comply with the section cited above by not having updated meical assessments for residents with dementia which poses a potential health, safety or personal rights risk to persons in care.
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Type B
11/11/2024
Section Cited
CCR87463(c)

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The licensee shall arrange a meeting with the resident, the resident’s representative,..., if any, when there is significant change in the resident’s condition, or once every 12 months, This requirement is not met as evidenced by:
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The facility agrees to review the needs and services plans for all residents and update any that are not dated or dated before 2024. Proof of correction will be sent to CCLD by POC date.
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Based on records review, the licensee did not comply with the section cited above by not having needs and services plan for four residents and having out dated ones for 16 residents, which poses a potential 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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