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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201046
Report Date: 05/07/2021
Date Signed: 05/07/2021 03:58:11 PM

Document Has Been Signed on 05/07/2021 03:58 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 RCFEFACILITY NUMBER:
079201046
ADMINISTRATOR:BOYKIN, MYNETTEFACILITY TYPE:
740
ADDRESS:1972 JEANETTE DRTELEPHONE:
(925) 798-7826
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 6CENSUS: 0DATE:
05/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mynette Boykin, Applicant/AdministratorTIME COMPLETED:
02:00 PM
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While at the facility conducting a Pre-Licensing inspection, Licensing Program Analyst (LPA) Praveen Singh conducted a Component III Orientation with Applicant/Administrator Mynette Boykin. Due to the Governor's present shelter in place order, this inspection was completed via phone-conference.

The Applicant/Administrator was provided with information to operate the facility within Title 22 regulatory compliance, as well as how to avoid common problem areas. Component III does not cover ALL regulations, only those found to be most problematic. Regulations require Administrator to be knowledgeable of all regulations and amendments to law.

Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Praveen Singh
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2021
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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