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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200056
Report Date: 12/09/2022
Date Signed: 12/09/2022 03:57:56 PM

Document Has Been Signed on 12/09/2022 03:57 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:ROSE RESIDENTIAL CARE FACILITYFACILITY NUMBER:
019200056
ADMINISTRATOR:CARBONEL, JONNASBURG DFACILITY TYPE:
735
ADDRESS:4704 ROSE WAYTELEPHONE:
(510) 441-2258
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 4DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:CARBONEL, JONNASBURG DTIME COMPLETED:
04:10 PM
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On 12/9/2022, at 2:50 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct Infection Control Inspection. LPA met with CARBONEL, JONNASBURG D, administrator (ADM) and explained the purpose of the visit.

During the inspection, LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, bathrooms, kitchen and backyard. LPAs observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed PPE's are plentiful. Food and paper supplies are sufficient. Hand sanitizer is provided at facility entrance. Water temperature is measured at 105.2 degrees F. Fire extinguisher was last serviced on 8/16/2022. First aid kit is complete. Smoke and carbon monoxide detectors were functional and maintained. Common areas are disinfected twice a day. LPA observed facility passages inside and out are free of obstruction.

During record review, LPA observed facility has a copy of Infection Control Plan and Emergency Disaster plan on file.

No deficiencies cited during visit.


Exit interview conducted with licensee and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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