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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126890101
Report Date: 08/09/2024
Date Signed: 08/13/2024 01:06:49 PM


Document Has Been Signed on 08/13/2024 01:06 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:ROSELAND CARE HOMEFACILITY NUMBER:
126890101
ADMINISTRATOR:SMITH, CLEOFACILITY TYPE:
740
ADDRESS:6449 PURDUE DRTELEPHONE:
(707) 442-3656
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:4CENSUS: DATE:
08/09/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:CLEO SMITHTIME COMPLETED:
01:30 PM
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Facility Type: RCFE
Application Type: CHOW EAO
Capacity: 4
Census (if any clients in care):
COMP II Participants: CLEO SMITH/ADMINISTRATOR AND APPLICANT
Interview Method: Telephone interview

On 8/9/24, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Stefania FontenoTELEPHONE: (916) 657-2335
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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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