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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201046
Report Date: 11/07/2024
Date Signed: 11/07/2024 12:16:43 PM

Document Has Been Signed on 11/07/2024 12:16 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ROSE COTTAGE RCFEFACILITY NUMBER:
079201046
ADMINISTRATOR/
DIRECTOR:		BOYKIN, MYNETTEFACILITY TYPE:
740
ADDRESS:1972 JEANETTE DRTELEPHONE:
(925) 798-7826
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 6CENSUS: 6DATE:
11/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Apollo McKarson, CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 11/07/2024 at 10:30am Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to Community Care Licensing Division (CCLD) on 07/30/2024. LPA met with Caregiver, Apollo McKarson and explained the purpose of the visit. Apollo called Licensee, Mynette Boykin and Administrator, Lisa Bermudez to inform.

On 07/30/2024, CCLD received a Death Report from Administrator indicating that R1 passed away on 07/27/24. The death report did not state whether R1 was on hospice at the time of their passing. The death report indicated that R1 had a stroke in 2014, was paralyzed, kidney failure and high blood pressure. The death report further indicated that S1 went to check on R1 and found them not breathing and they called 911 and the family.

LPA interviewed S1 that stated R1 was declining and that they called the family to inform but the family did not want to send their mother to the hospital. S1 stated that they tried to advise the family that R1's health was declining and that they should place R1 on hospice but the family refused. S1 further stated that they called 911 and told 911 emergency that the resident was declining but the family did not want R1 to go to the hospital. S1 stated that the 911 call representative stated to them if the family refuses to send R1 to the hospital that the family is the one responsible. S1 stated that R1 passed away the following day.

LIC809-C (Next Page)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ROSE COTTAGE RCFE
FACILITY NUMBER: 079201046
VISIT DATE: 11/07/2024
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LIC809-C Continued (Page 2)

LPA interviewed S2 over the phone and S2 stated that R1 had a stroke 10 years ago and just started rapidly declining. S2 stated that the family was putting R1 on hospice at the end.

LPA requested copies of R1's physician's report, appraisal needs and services, MAR, doctors orders, care notes, copy of police report and a copy of death certificate. LPA spoke with S2 over the phone and S2 stated that they have R1's records at the office and that they can have the documents tomorrow. LPA advised S2 to fax/e-mail the documents to LPA later today, 11/07/24.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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