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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601188
Report Date: 05/12/2023
Date Signed: 05/12/2023 11:24:47 AM


Document Has Been Signed on 05/12/2023 11:24 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:ROSARIO'S CARE HOMEFACILITY NUMBER:
015601188
ADMINISTRATOR:TENGAN, GERIFACILITY TYPE:
740
ADDRESS:14548 ELM STREETTELEPHONE:
(510) 614-5819
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY:5CENSUS: 0DATE:
05/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Geri Tengan, AdministratorTIME COMPLETED:
11:30 AM
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On 5/12/2023 at 9:30 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Geri Tengan and explained the purpose of the visit. The facility’s fire clearance was approved for 5 Non-Ambulatory. Facility currently does not have residents.

LPA toured facility with Geri including but not limited to bathroom, kitchen, common area and backyard. The facility consists of 3 total bedrooms which are currently occupied by Administrator and their family. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate. The hot water temperature in the residents’ shared bathroom was measured at 105 degrees Fahrenheit. Bathroom is equipped with grab bars and non-skid mats. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Closet where centrally stored medication would be stored and sharps were locked and inaccessible to future residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed. First aid kit was observed to be complete.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
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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