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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200531
Report Date: 02/04/2022
Date Signed: 02/04/2022 03:15:10 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 HOMEFACILITY NUMBER:
079200531
ADMINISTRATOR:ZINA LEEFACILITY TYPE:
740
ADDRESS:1972 JEANETTE DRIVETELEPHONE:
(925) 798-7826
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:6CENSUS: 6DATE:
02/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Apollo Mckarson, CaregiverTIME COMPLETED:
03:30 PM
NARRATIVE
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On 2/4/2022 at 10:25 a.m., while Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced Pre-Licensing inspection for changing ownership to Rose Cottage RCFE (#079201046), LPA observed the following deficiencies. Both facility Licensee and Administrator were unavailable during inspection. Licensee Mynette Boykin authorized caregiver Apollo Mckarson to give tour to LPA and sign on the report.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:

At 10:26 a.m. Centrally stored medication located in the kitchen cabinet was unlocked.
At 10:26 a.m. Centrally stored knives under the sink in the kitchen was unlocked.
At 11:30 a.m. Staff records were observed incomplete while doing record review.
At 12:15 p.m. Used needles were disposed in a opened plastic bag.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.




Exit interview conducted with Caregiver. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/05/2022
Section Cited

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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(2) Medication...cleaning supplies and disinfectants.

This requirement is not met as evidenced by…
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Based on observation, interview, and record review, the licensee did not comply with the section cited above, LPA observed a centrally stored medication in the kitchen was unlocked which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
02/05/2022
Section Cited

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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by…
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Based on observation, interview, and record review, the licensee did not comply with the section cited above, LPA observed a centrally stored knives cabinet under the sink in the kitchen was unlocked which poses an immediate health, safety or personal rights 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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/18/2022
Section Cited

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87303 Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows:
(2) Needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens.

This requirement is not met as evidenced by…
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Based on observation and interview, the licensee did not comply with the section cited above, where used needles were disposed in a opened plastic bag which posed a potential health, safety or personal rights risk to persons in care.
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Type B
02/18/2022
Section Cited

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87412 Personnel Records

This requirement is not met as evidenced by…
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Based on record review, the licensee did not comply with the section cited above, where incomplete personnel records were observed which posed a potential health, safety or personal rights 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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3