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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201046
Report Date: 02/18/2022
Date Signed: 02/18/2022 03:30:48 PM

Document Has Been Signed on 02/18/2022 03:30 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:
02/18/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Mynette Boykin, Applicant/LicenseeTIME COMPLETED:
03:40 PM
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On 2/18/2022 at 2:30 PM, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct the 3rd Pre-licensing inspection. LPA met with Applicant/Licensee, Mynette Boykin and explained the purpose of the visit. The facility currently has 6 residents because it's a changing of ownership.

LPA toured facility, reviewed records of staff and residents, inspected four deficiencies cited on 2/4/22, and confirmed that deficiencies have been corrected.

Component III Orientation had been conducted previously with Mynette Boykin by LPA Praveen Singh on 5/21/2021, therefore it's waived at this time.

No issues noted during inspection. LPA observed that facility is 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.

Exit interview conducted with Administrator and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2022
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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