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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201046
Report Date: 02/04/2022
Date Signed: 02/04/2022 03:12:49 PM

Document Has Been Signed on 02/04/2022 03:12 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: 6DATE:
02/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Apollo Mckarson, CaregiverTIME COMPLETED:
03:30 PM
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On 2/4/2022 at 10:25 a.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct the 2nd Pre-Licensing inspection. LPA met with Caregiver Apollo Mckarson and explained the purpose of the visit. Both facility Licensee and Administrator were unavailable during inspection. Licensee Mynette Boykin authorized caregiver Apollo to give tour to LPA and sign on report. The facility currently has 6 residents including 4 non-ambulatory and 2 ambulatory.

LPA toured facility including but not limited to 6 bedrooms, 2 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 72 degrees F and hot water temperature was maintained at 113 degrees F. First-aid kit was observed to be complete. Smoke detector and Carbon monoxide were operational. Fire extinguisher was last serviced in Feb 2021.

Prior to licensure, the following shall be corrected and faxed to CCL by 2/18/2022.
  • Centrally stored medication was unlocked, in-services training is required.
  • Centrally stored knives was unlocked, in-services training is required.
  • Staff personnel records are required to be completed
  • Used needles were disposed in a opened plastic bag, a secured container for disposed needles is required.


Continue on LIC809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
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)
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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 RCFE
FACILITY NUMBER: 079201046
VISIT DATE: 02/04/2022
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Issues were noted during inspection. LPA observed that facility is not ready to be licensed. This report will be submitted to the Central 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.

Component III was not conducted at this time due to absence of Licensee and Administrator. Exit interview conducted with Caregiver, and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
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
LIC809 (FAS) - (06/04)
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