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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803624
Report Date: 08/10/2021
Date Signed: 08/10/2021 10:40:25 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ROSES RESIDENTIAL CARE FACILITYFACILITY NUMBER:
216803624
ADMINISTRATOR:ABDISHIOU, ROBERTFACILITY TYPE:
740
ADDRESS:1 ROOSEVELT AVETELEPHONE:
(415) 479-9638
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:8CENSUS: 7DATE:
08/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Administrator, Silvana DanielTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Roses Residential Care Facility for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Leidy Vargas. Administrator, Silvana Daniel arrived 10 minutes later.

LPA toured the facility with Silvana Daniel. Facility was found to be clean and at a comfortable temperature. During the tour at 09:30 AM, LPA observed the exit by bedroom 3 and 4 being obstructed by a wheelchair and painting materials (See LIC 809D- Photograph taken). Fire Extinguisher was found to be last charged on 2/2021 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected, and inspection records are current. LPA observed Carbon monoxide detector that was found to be operational during the visit. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured at 114 degrees F within acceptable range of 105 to 120 degrees. Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. Food is available for residents any time of the day. Toxins are stored in a locked laundry room cabinet. There was a supply of cleaners, hygiene products and paper products available for residents.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the medicine cabinet Staff have had all PPE training required and have been N95 Fit tested. Mitigation Plan reviewed at the facility with the Administrator.

Deficiencies were observed on August 10, 2021 at 09:30 AM during a facility tour, and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Immediate Civil Penalty assessed. Appeal rights were given. Exit interview was conducted and a copy of this report was signed and given to the Administrator, Silvana Daniel.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ROSES RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 216803624
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203-All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and interview with the Administrator, the facility failed to be in conformity by blocking the exit with a wheelchair and painting materials. In addition, this exit is for residents and leads to the front of the facility. This poses an immediate health and safety risk to residents in care. **Immediate Civil Penalty assessed in the amount of $500**.
POC Due Date: 08/17/2021
Plan of Correction
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Administrator to ensure walkways and exits are unobstructed. Licensee to review fire code regulations and submit self-certification that items blocking exits have been removed. Administrator removed the items blocking immediately. Administrator shall provide proof of training on fire code regulations by August 17, 2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2021
LIC809 (FAS) - (06/04)
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