079200531-6-26-2021-15-AS-DPAO-C4D3G6-20210626181350

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200531
Report Date: 06/26/2021
Date Signed: 06/26/2021 06:14:08 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 COTTAGE ELDERLY HOME		FACILITY NUMBER:	079200531
ADMINISTRATOR:	ZINA LEE		FACILITY TYPE:	740
ADDRESS:	1972 JEANETTE DRIVE		TELEPHONE:	(925) 798-7826
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS: 6	DATE:	06/26/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	05:00 PM
MET WITH:	Apollo McKarsen, House Manager		TIME COMPLETED:	06:28 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	On 06/26/21 at 5PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with the house manager. LPA spoke with administrator on the phone who authorized house manager to sign the reports. LPA observed 2 staff wearing face masks during visit with 6 residents relaxing in their bedrooms during visit. Facility has a completed mitigation plan in place dated 06/01/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with licensee as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom check) is done at entry for all staff, residents and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2021

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 COTTAGE ELDERLY HOME	FACILITY NUMBER: 079200531
	VISIT DATE: 06/26/2021

NARRATIVE

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A written Emergency/Disaster plan dated 11/20/20 was posted in the living room. Centrally stored medications were locked in kitchen cabinets. Sharp objects were locked in the kitchen drawers. Toxic chemicals were locked in the laundry room. Facility has conducted staff training on infection prevention, symptoms, transmission and proper donning & doffing of PPE.

Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since February 1, 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 75 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was observed fully charged and last inspected on 02/2021. Smoke and Carbon monoxide detectors were operational.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 07/07/2021:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2021

LIC809 (FAS) - (06/04)

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