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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200760
Report Date: 11/30/2021
Date Signed: 11/30/2021 01:58:54 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:
11/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Angela Wang, Licensee, and Lili Xu, AdministratorTIME COMPLETED:
02:10 PM
NARRATIVE
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On 11/30/2021 at 01:35PM Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported by the Department during a complaint investigation. LPA met with Angela Wang Owner and Lili Xu, Administrator and explained the purpose of the visit.

During the Department’s investigation regarding complaint 15-AS-20201116095524, it was determined that the facility failed to submit incident reports for one of the resident’s eloping from the facility twice. During the interview S1 stated she was unaware that an incident report needed to be submitted for elopements. During interviews with staff it was disclosed that nails were placed in the facility doors to prevent residents from eloping. Staff expressed the difficulty in removing the nails during an emergency. LPA toured facility and did not observe where nails was placed on doors.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. Appeal rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
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 ARBOR SENIOR RESIDENTIAL CARE, LLC
FACILITY NUMBER: 019200760
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2021
Section Cited

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87211(a) ...licensee shall furnish... reports as the Department may require... (1)A written report shall be submitted to the licensing... within seven days of the occurrence... (D)Any incident which threatens the welfare, safety or health of any resident...
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This requirement was not met as evidence by: Based on record review Licensee did not comply with the section cited above in reporting an incident, which poses a potential health and safety risk to persons in care.
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021
LIC809 (FAS) - (06/04)
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