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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200661
Report Date: 08/18/2021
Date Signed: 08/18/2021 03:26:30 PM

Document Has Been Signed on 08/18/2021 03:26 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 GARDEN VISTAFACILITY NUMBER:
019200661
ADMINISTRATOR:BAUTISTA, HAIDIEFACILITY TYPE:
735
ADDRESS:1615 HIGH STREETTELEPHONE:
(510) 533-4929
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY: 15CENSUS: 12DATE:
08/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Haidei BautistaTIME COMPLETED:
03:45 PM
NARRATIVE
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On 8/18/2021 at 1:56 PM, Licensing Program Analysts (LPA) Leslie Ibo & Greg Clark conducted an infection control annual inspection and explained the purpose of the visit with Haidie Bautista. LPAs observed 12 clients during the visit. Facility has a completed mitigation plan. LPAs inspected the facility inside and outside. LPAs observed COVID-19 posters posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards.

Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 72 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.



Continued on next page LIC 809-C…
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2021
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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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 GARDEN VISTA
FACILITY NUMBER: 019200661
VISIT DATE: 08/18/2021
NARRATIVE
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LPAs observed the following:
· Facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use.

· 3 Common bathrooms were observed without paper towel- Corrected 8/18/2021.


Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Haidie Bautista

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/18/2021 03:26 PM - It Cannot Be Edited


Created By: Leslie Ibo On 08/18/2021 at 02:59 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 GARDEN VISTA
FACILITY NUMBER: 019200661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)(B)


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 the 3 common bathrooms do not have available paper towels for staff, visitors and clients in carewhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2021
Plan of Correction
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Administrator will make sure that staff are trained or reminded to ensure all common bathrooms has available paper towel for clients, visitors and staffs. - CLEARED AND CORRECTED 8/18/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/18/2021 03:26 PM - It Cannot Be Edited


Created By: Leslie Ibo On 08/18/2021 at 03:13 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 GARDEN VISTA
FACILITY NUMBER: 019200661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)(5)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (5) Recognition of early signs of illness and the need for professional assistance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2021
Plan of Correction
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Facility Administrator will train all staffs and document training. Administrator will need to submit proof of training on or before POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2021


LIC809 (FAS) - (06/04)
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