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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200760
Report Date: 11/18/2020
Date Signed: 11/18/2020 06:04:41 PM

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 ARBOR SENIOR RESIDENTIAL CARE, LLCFACILITY NUMBER:
019200760
ADMINISTRATOR:XU, LILIFACILITY TYPE:
740
ADDRESS:5901 ROSE ARBOR AVETELEPHONE:
(510) 366-9618
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:12CENSUS: 2DATE:
11/18/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Lili Xu, AdministratorTIME COMPLETED:
06:00 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
Licensing Program Analyst (LPA) Praveen Singh conducted a Case Management health and safety tele-inspection with Administrator Lili Xu, in relation to the Department receiving a priority 2 complaint. This inspection was conducted via video-conference due to the present shelter in place order by the Governor.

During the tele-inspection, LPA toured the facility with S2, including but not limited to the kitchen, dining room, garage, living space, and outside areas. LPA observed a sufficient supply of perishable and non-perishable foods. LPA observed locked drawers and cabinets for sharps, cleaning supplies and medications. LPA observed passageways appeared to be free of obstruction. LPA was informed by Administrator that everything was in good repair and no disruption to utilities.

No deficiencies cited during inspection. Exit interview conducted and a copy of the report emailed to Administrator.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020
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 1