<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200056
Report Date: 12/08/2023
Date Signed: 12/08/2023 02:36:33 PM

Document Has Been Signed on 12/08/2023 02:36 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:
12/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Jonnasburg CarbonelTIME COMPLETED:
02:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day at around 10:20 am, Licensing Program Analyst (LPA) arrived unannounced to conduct an annual required inspection and met with Administrator Jonnasburg Carbonel. LPA explained the Administrator the purpose of the visit. The facility is a Level 41 home vendorized by the Regional Center of the East Bay (RCEB).

During the visit, LPA toured facility inside and out including but not limited to kitchen, client bedrooms, bathrooms, dining room, living room, and backyard. Smoke detectors and carbon monoxide were tested and observed in operational condition. Last fire drill was conducted on 12/5/2023. Fire extinguisher was observed to be full and was last serviced on 8/28/2023 . Hot water in the kitchen was measured at 115 degrees F. Bathrooms/shower area have non skid mats. There are a minimum of 7-day non-perishable and 2-day perishables foods. There is an adequate supply of toiletries, hygiene supplies, and extra linens. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. All indoor and outdoor passageways were observed free of obstruction. There are no bodies of water observed.

At 11am, LPA reviewed 4 client files and 3 staff files. At 12:40, LPA reviewed P&I money and log with Administrator. Facility has surety bond sufficient to cover amount of cash being handled at one time. At , LPA reviewed first aid kit and observed it to be complete.

The following deficiencies were observed:
  • a client using gait belt did not have doctor order/approved exception
  • carpet in the living area were observed heavily stained

Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
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 3
Document Has Been Signed on 12/08/2023 02:36 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 12/08/2023 at 01:47 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: ROSE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(8)(B)
Personal Rights
(B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in not having doctor's order/approved exception for C4 who uses gait belt when using wheelchair which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
1
2
3
4
Administrator will submit a request for exception to CCL by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/08/2023 02:36 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 12/08/2023 at 01:47 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: ROSE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having stained carpets in the living area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
1
2
3
4
Administrator states carpets will be replaced in 30 days and submit photo proof of completion. Administrator will submit plans to ensure clients are safe during the process before removing carpet.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3