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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200056
Report Date: 11/30/2023
Date Signed: 11/30/2023 03:43:35 PM

Document Has Been Signed on 11/30/2023 03:43 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:
11/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jonnasburg CarbonelTIME COMPLETED:
04:00 PM
NARRATIVE
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On this day at around 1:40 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management visit in regards to a self-reported fall incident. LPA met with Administrator Jonnasburg Carbonel.

During the visit, LPA reviewed incident report, hospital discharge and Medication Administration Record (MAR). LPA interviewed Client 1 (C1). LPA observed C1 takes Motrin for pain on as needed basis. However, the facility does not have any order from C1's doctor. LPA also inspected the bathroom where C1 fell and observed rugs that are non skid.

Deficiencies are cited per Title 22 California Code of Regulations(see 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: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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 2
Document Has Been Signed on 11/30/2023 03:43 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 11/30/2023 at 03:07 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: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
Section Cited
CCR
80087(b)(1)

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80087 Buildings and Grounds
(1) Protective devices including but not limited to nonslip material on rugs
This requirement is not met as evidenced by:
Based on observation, facility failed to provide nonslip rugs in the bathroom which poses a potential risk to health and safety of
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Administrator removed all rugs and will purchase nonslip rugs; will submit proof of purchase and photo proof.
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clients under care.
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Type B
11/30/2023
Section Cited
CCR80075(b)(5)(A)

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80075 Health Related Services
(A) There is a written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of ....
This requirement is not met as evidenced by: Based on record review, facility gave C1 Motrin without doctor's order.
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Administrator obtained doctor's order during visit.
This deficiency is cleared.
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
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