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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200531
Report Date: 04/27/2022
Date Signed: 04/27/2022 04:04:02 PM


Document Has Been Signed on 04/27/2022 04:04 PM - 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: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: 4DATE:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Apollo Mckarson, CaregiverTIME COMPLETED:
04:15 PM
NARRATIVE
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On 04/27/2022 at 2:30 pm, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with caregiver, Apollo Mckarson and explained the purpose of the visit.

Upon entry, LPA observed screening station that contained hand sanitizer, masks and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. 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 posters.

During record review, LPA observed visitors log and temperature logs for residents or staff. LPA observed facility has a copy of Mitigation Plan on file.

The following deficiencies were observed during the visit:

-At 2:35pm, LPA observed S2 was not associated to facility.
-At 2:43pm, LPA observed soiled carpet.
-At 2:50pm LPA observed garage door unlocked with cleaning supplies and tools in the garage.

The 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. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
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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Document Has Been Signed on 04/27/2022 04:04 PM - It Cannot Be Edited

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: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(2)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care. S2 (Staff #2) is not associated to the facility.
POC Due Date: 04/28/2022
Plan of Correction
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Administrator will associate/transfer S2 criminal record clearance to facility and provide proof to CCLD no later than the POC date.
Type A
Section Cited
CCR
87705(f)(1)(2)
(f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care. Garage door lock is from the inside out and the garage has cleaning supplies and tools.
POC Due Date: 04/28/2022
Plan of Correction
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Administrator will change the lock around to lock from the outside in to make cleaning supplies and tools inaccessible to residents and provide photo copies to CCLD no later than the POC date.

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: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/27/2022 04:04 PM - It Cannot Be Edited

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: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Administrator will hire a carpet cleaning company to shampoo the carpet in room #1 and provide CCLD with a copy of the contract and photo copies of the carpet no later than the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3