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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201046
Report Date: 05/21/2021
Date Signed: 05/21/2021 04:24:43 PM

Document Has Been Signed on 05/21/2021 04:24 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:
05/21/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Mynette Boykin, Administrator/ApplicantTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Praveen Singh continued a Pre-licensing Inspection initiated on 5/7/21. Due to the Governor's present shelter in place order, this inspection was completed via phone conference with Applicant/Administrator Mynette Boykin.

LPA conducted a complete Pre-Licensing inspection and a Comp III Review with Applicant/Administrator on 5/7/21. LPA observed the facility was ready to be licensed with the exception of a matter concerning the facility's Fire Clearance. On 5/7/21, the Fire Department reissued a Fire Clearance for a capacity of five (5) non-ambulatory and one (bedridden).

LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided via email.

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SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Praveen Singh
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2021
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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