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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200760
Report Date: 10/29/2021
Date Signed: 10/29/2021 01:10:26 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: 0DATE:
10/29/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Lili Xu, AdministratorTIME COMPLETED:
01:20 PM
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On 10/29/21 at 12:15PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an annual infection control inspection and met with administrator (ADM). LPA explained the purpose of the visit with ADM.

LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. LPA observed no residents or staff present at the facility. ADM told LPA that the licensee/owner has placed the building for sale and the facility has been vacant for over 2 months.

LPA observed no COVID signages posted inside the facility. ADM stated that the licensee/owner took them all down so that the realtor could show the property to prospective buyers as a conventional home. ADM stated that if the building is not sold in 2 months, licensee/owner will decide whether to start operating the care home again. Since there are no residents nor staff present at the facility, LPA observed no food supplies at the facility.

LPA discussed the mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. Infection control designated leader is the ADM who has been fully vaccinated since March 2021.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
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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