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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200165
Report Date: 06/22/2022
Date Signed: 06/22/2022 10:32:37 AM

Document Has Been Signed on 06/22/2022 10:32 AM - 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:ROSES GARDEN ADULT RESIDENTIAL CARE-ROSSELEN PENAFACILITY NUMBER:
079200165
ADMINISTRATOR:ROSA ELENA MENJIVARFACILITY TYPE:
735
ADDRESS:3408 BLYTHE DRIVETELEPHONE:
(925) 864-7564
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 4DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Cristina Luna-Vasquez, CaregiverTIME COMPLETED:
10:40 AM
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
On 6/22/2022 at 9:45AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Cristina Luna-Vasquez, Caregiver, and explained the purpose of the visit.

Upon entry, LPA's temperature was not checked. LPA observed screening station that contained hand sanitizer, sign-in book, and COVID posters. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage, and back
yard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing poster. Hot water temperature in the shared clients’ bathroom was measured at 104.3 degrees Fahrenheit. Fire extinguisher was last serviced on 11/19/2019.

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food and paper supplies are sufficient.

The following forms are to be updated and submitted to CCLD by 6/29/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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 2
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: ROSES GARDEN ADULT RESIDENTIAL CARE-ROSSELEN PENA
FACILITY NUMBER: 079200165
VISIT DATE: 06/22/2022
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
26
27
28
29
30
31
32
Continued from LIC809.

-LIC610D Emergency Disaster Plan
-A copy of current Administrator certificate.

No deficiencies cited during inspection.

Exit interview conducted. A copy of this reported.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2