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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150400536
Report Date: 03/25/2025
Date Signed: 04/02/2025 10:10:11 AM

Document Has Been Signed on 04/02/2025 10:10 AM - 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:ROSEWOOD RETIREMENT COMMUNITYFACILITY NUMBER:
150400536
ADMINISTRATOR/
DIRECTOR:		BALABAN, ROCHELLEFACILITY TYPE:
741
ADDRESS:1301 NEW STINE ROADTELEPHONE:
(661) 834-0620
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 220TOTAL ENROLLED CHILDREN: 0CENSUS: 138DATE:
03/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Rochelle BalabanTIME VISIT/
INSPECTION COMPLETED:
07:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Katie Brown and Jimmy Duarte arrived unannounced to conduct the Annual Inspection. LPAs met with and explained the reason for the visit with Administrator (AD) Rochelle Balaban

During this visit, LPAs toured the facility inside & out. Resident rooms and common areas were clean, in good repair and contained required equipment, furnishings and lighting. LPAs observed required items in bathrooms (including shower mats & grab bars) which were clean with hot water measuring between 105 and 108 degrees. LPAs observed hygiene items, paper products, towels, extra bedding, and linens which were stored and available for use. The kitchen was found to be clean, in good repair with necessary items and appliances. LPAs observed required food supply, emergency food, water, and paper products. Medications are centrally stored in locked medication carts on each floor. Doors and passageways are unobstructed throughout the facility including outdoors. First aid kits contained required items.

LPAs walked the outdoors to find the grounds well-kept with clear walkways with sitting areas. The in ground pool was gated and locked as required. Fire extinguishers were charged and serviced on 3/5/25 by Independent Fire Co. Bakersfield Fire Department conducted fire safety, sprinkler system and boiler system inspection 1/25/25. LPAs conducted resident and staff file reviews as well as a medication audit. Emergency/ Disaster and Infection Control procedures and requirements were reviewed during the inspection.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of: Hospice Care for Terminally Ill Residents, Incidental Medical and Dental Care, Oxygen Administration and Storage Space and Access - See LIC809C for continuation of this report
Sergiy PidgirnyTELEPHONE: (559) 246-0610
Katie BrownTELEPHONE: (559) 498-9964
DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/02/2025 10:10 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: ROSEWOOD RETIREMENT COMMUNITY
FACILITY NUMBER: 150400536

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87309(b)
Storage Space and Access
(b) Residents may have access to items specified in subsection (a) for personal use unless there is documentation, as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Medications were found in the rooms of R5 and R6. Chemicals/cleaning supplies found in rooms R4, housekeeping cart in memory care was unattended in hallway with accessible disinfecting cleaner, memory care bathroom cabinet was not locked but stored disinfecting cleaner.
POC Due Date: 03/26/2025
Plan of Correction
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Licensee has agreed to remove medications and cleaning supplies from R5 and R6 rooms, housekeeping staff will receive in-service 3/26/25, sign in sheet to be submitted to CCLD, a work order has been placed to repair bathroom cabinet lock. A written statemen will be submitted to state all above has been completed by poc date.
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. R5 - Senna start date 3/20/25 1 tab QD. 30 day supply, there should be 24 pills but there are 26 pills remaining. 2 pills not given as ordered. R6 - Lasix - Start date 2/19/25 order states 1 pill every 2 days. From 2/19/25-3/25/25 - 18 pills should have been given. There should be 72 pills remaining but there are 71. 1 pill ws not given as ordered.
POC Due Date: 03/26/2025
Plan of Correction
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Licensee has agreed to provide in-service to all Resident Assistants and LVNs on medication policy and procedure, including Centrally Stored Medication log. A statement will be submitted by poc date of reaining plan including completiion date. Sign in sheet will be submitted by 4/15/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sergiy PidgirnyTELEPHONE: (559) 246-0610
Katie BrownTELEPHONE: (559) 498-9964

DATE: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/02/2025 10:10 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: ROSEWOOD RETIREMENT COMMUNITY
FACILITY NUMBER: 150400536

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. The facility did not maintain a current hospice plan of care for R1. R2 or R3. The care plans for all 3 residents were obtained from the hospice agencies during the visit.
DEFICIENCY CLEARED
POC Due Date: 03/25/2025
Plan of Correction
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DEFICIENCY CLEARED DURING INSPECTION.
Type B
Section Cited
CCR
87618(a)(1)
87618 Oxygen Administration - Gas and Liquid (a) Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who requires the use of oxygen gas administration under the following circumstances: (1) If the resident is mentally and physically capable of operating the equipment, is able to determine his/her need for oxygen, and is able to administer it him/herself.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. R4 and R5 are on Oxygen as ordered by their Physician. Both Physician's Reports indicate that they cannot administer own Oxygen.
POC Due Date: 04/15/2025
Plan of Correction
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Licensee has agreed to obtain a new and updated Physician's Report for R4 and R5. The updated reports will be submitted by poc date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sergiy PidgirnyTELEPHONE: (559) 246-0610
Katie BrownTELEPHONE: (559) 498-9964

DATE: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025

LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ROSEWOOD RETIREMENT COMMUNITY
FACILITY NUMBER: 150400536
VISIT DATE: 03/25/2025
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Annual continuation:

An exit interview was conducted and Plan of Correction (POC) developed. A signed copy of this report and Appeal Rights were provided.

LPA requested the following updated forms faxed to CCLD by 4/15/25: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Personnel Report (LIC 500), Client Roster (LIC 9020) and Proof of current Liability Coverage.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC809 (FAS) - (06/04)
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