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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803624
Report Date: 08/26/2021
Date Signed: 08/26/2021 12:54:27 PM

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: 5DATE:
08/26/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Administrator, Silvana DanielTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Roses Residential Care Facility for the purpose of conducting a Plan of Correction (POC) inspection. LPA was greeted outside and granted access into the facility.

During this POC inspection, LPA observed no hazardous items or obstructions blocking the exit. LPA cleared the citation and Plan of Correction (POC) has been fulfilled.

LPA reiterated repeated deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted and a copy of this report along with the Plan of Correction clearance was emailed to Administrator, Silvana Daniel.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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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