Community Care Licensing

Document Has Been Signed on 03/19/2025 05:27 PM - It Cannot Be Edited

FACILITY NAME:	ROSE COTTAGE RCFE		FACILITY NUMBER:	079201046
ADMINISTRATOR/ DIRECTOR:	BOYKIN, MYNETTE		FACILITY TYPE:	740
ADDRESS:	1972 JEANETTE DR		TELEPHONE:	(925) 798-7826
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY: 6		CENSUS: 5	DATE:	03/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Lisa Bermudez, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:45 PM

SUPERVISORS NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025

Link to Parent Document Below:

FACILITY NAME: ROSE COTTAGE RCFE	FACILITY NUMBER: 079201046
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2025

Type B

Section Cited

HSC

1569.605

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having current Liability Insurance Certificate available which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/08/2025
	Plan of Correction
1 2 3 4	Administrator agreed to send a copy of liability insurance to CCLD by POC due date.

Type B

Section Cited

HSC

1569.618(c)(3)

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having current First Aid/CPR for S4 and S5 which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/08/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit First Aid/CPR Certificates for S4 and S5 to CCLD by POC due date. Repeat Violation. Assessed civil penalty $250.00

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025

Link to Parent Document Below:

FACILITY NAME: ROSE COTTAGE RCFE	FACILITY NUMBER: 079201046
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2025

Type B

Section Cited

CCR

87463(a)

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having a updated appraisal for R5 which includes but not limited the care for foley catheter, diabetes and bedridden care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2025
	Plan of Correction
1 2 3 4	Administrator agree to submit an updated Appraisal Needs and Services for R5 and submit to CCLD by pOC due date.

Type B

Section Cited

HSC

1569.695(a)

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in by not having an updated Emergency and Disaster Plan (LIC610E) that includes but not limited bedridden resident and all pages are available and reviewed annually which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2025
	Plan of Correction
1 2 3 4	Administrator agree to submit an updated Emergency Disaster Plan and submit to CCLD by POC due date.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025

Link to Parent Document Below:

FACILITY NAME: ROSE COTTAGE RCFE	FACILITY NUMBER: 079201046
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2025

Type B

Section Cited

CCR

87608(a)(5)(A)

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in by not having on a file a doctor's order for 1/2 rail bed for R3 and hospital bed with full rails for R5 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit copies of doctor's orders to CCLD by POC due date.

Type B

Section Cited

CCR

87632(d)(2)

87632 Hospice Care Waiver (d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in by not notifying CCLD hospice initiation of services for R2 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2025
	Plan of Correction
1 2 3 4	Administrator agree to read the regulation and self-certify that they read/understand and will comply moving forward with this regulation. Also, send notice of hospice initated services for R4 to CCLD by POC due date.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025

Link to Parent Document Below:

FACILITY NAME: ROSE COTTAGE RCFE	FACILITY NUMBER: 079201046
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2025

Type B

Section Cited

CCR

87606(f)(1)(A)

87606 Care of Bedridden Residents (f) To accept or retain a person who is bedridden, a licensee shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the licensee intends to meet the overall health, safety and care needs of residents who are bedridden. (A) The facility's Emergency and Disaster Plan addresses fire safety precautions specific to evacuation of residents who are bedridden in the event of an emergency or disaster. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in by not having including but not limited a Plan of Operation on file for bedridden which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2025
	Plan of Correction
1 2 3 4	Administrator agree to submit updated Plan of Operation that reflects care of presons bedridden to CCLD by POC due date.

Type B

Section Cited

CCR

87628(a)

87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in by having a physician's report that indicates R5 can do their own blood glucose checks and administer their own insulin injections which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/08/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit an updated physician's report that indicates by R5's primary care physician that R5 can administer their own injections and blood glucose checks and send copy to CCLD by POC due date.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025

FACILITY NAME: ROSE COTTAGE RCFE	FACILITY NUMBER: 079201046
	VISIT DATE: 03/19/2025

Link to Parent Document Below:

FACILITY NAME: ROSE COTTAGE RCFE	FACILITY NUMBER: 079201046
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2025

Type B

Section Cited

CCR

87623(b)(2)

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that the bag and tubing are changed by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in by not having documentation of R5's foley catheter on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2025
	Plan of Correction
1 2 3 4	Administrator will submit an exception letter for R5 with supporting documents that includes but not limited to a Physician's Report (LIC602A), Home Health Care Plan, ANS, and staff that was trained by an appropriate licensed health professional to CCLD by POC date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025