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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200056
Report Date: 12/11/2024
Date Signed: 12/11/2024 05:09:45 PM

Document Has Been Signed on 12/11/2024 05:09 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/
DIRECTOR:		CARBONEL, JONNASBURG DFACILITY TYPE:
735
ADDRESS:4704 ROSE WAYTELEPHONE:
(510) 441-2258
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 4DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Jonnasburg CarbonelTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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On 12/11/2024 at around 2:45 am, Licensing Program Analysts (LPAs) L. Fontanilla and D. Doidge arrived unannounced to conduct an annual required inspection and met with Administrator Jonnasburg Carbonel. LPAs 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, LPAs 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 12/3/2024. Fire extinguisher was observed to be full and was last serviced on 9/23/2024 . Hot water in the kitchen was measured at 112 degrees F. Bathrooms/shower area have non skid mats. There is a minimum of 7-day non-perishable and 2-day perishables foods. There is an adequate supply of toiletries, hygiene supplies, and extra linens. LPAs 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 2:55 PM, LPAs reviewed 4 client files and 6 staff files. At 3:00 PM, LPAs reviewed P&I money and log with Administrator. Facility has surety bond sufficient to cover amount of cash being handled at one time. At 3:56 PM, LPAs reviewed first aid kit and observed it to be complete. At 4pm, LPAs reviewed medication and medication administration record (MAR).

continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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 12/11/2024 05:09 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 12/11/2024 at 04:41 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: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation, the licensee did not comply with the section cited above in: 1) having wall under sink with mold, 2) screen window with tiny holes and not fitting frame, 3) refrigerator door not closing 4) backyard fence shaky and leaning towards neighbor side which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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By POC date, the Administrator will send photo proof of 1) repaired wall 2) replaced window screen 3) fix refrigerator door 4) fixed fence
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having unlocked Clorox and comet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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The Administrator locked away chemicals during the visit. This deficiency is cleared during the visit.
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: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
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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: ROSE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200056
VISIT DATE: 12/11/2024
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The following records will be submitted to CCL by Friday, 12/13/2024:
  • Infection Control Plan
  • Lic 500
  • Disaster Plan
  • Surety bond
  • Client Roster

Deficiencies were cited per Title 22 California Code of Regulations (refer to Lic 809D).

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: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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