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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200760
Report Date: 10/22/2021
Date Signed: 10/22/2021 10:02:33 AM

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: 0DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
10:00 AM
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On 10/22/2021 at 09:30AM Licensing Program Analysts (LPA) C. Fowler and L. Hall attempted to conduct an unannounced required 1-year inspection. Upon arrival LPAs observed a for sale sign in front yard. LPAs approached the facility and observed a key pad lock on the front gate. LPAs telephoned Lili Xu, Administrator and left message to return call.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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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