312700403-8-31-2021-25-AS-DAWL-C6EPN9-20210831112733

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 312700403
Report Date: 08/31/2021
Date Signed: 08/31/2021 11:28:08 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	ROSE GARDEN SENIOR CARE		FACILITY NUMBER:	312700403
ADMINISTRATOR:	LOPEZ, DOINA		FACILITY TYPE:	740
ADDRESS:	6130 EAGLECREST WAY		TELEPHONE:	(916) 872-1837
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95765
CAPACITY:	6	CENSUS: 5	DATE:	08/31/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:36 AM
MET WITH:	Doina Lopez, Administrator		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On August 31, 2021, at 9:30am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a required 1 year inspection. LPA met with Doina Lopez Executive Director and explained purpose of inspection. Prior to initiating the inspection LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: mask. Additionally, LPA was screened by the front desk personnel upon arrival. Carmen and LPA completed the inspection tool questionnaire with no issues or advisories to report. The Administrator Certificate expires 8/13/2023. Currently, the facility has 5 residents residing in the home. The home was 78 degrees F. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. Hot water temperatures were taken and measured at 10 degrees F. There’s appropriate lighting throughout the facility. Living room, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident bedrooms and bathrooms were toured. There are 5 Bedrooms and 3 bathrooms for residents. All rooms had the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

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, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROSE GARDEN SENIOR CARE	FACILITY NUMBER: 312700403
	VISIT DATE: 08/31/2021

NARRATIVE

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The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer was present and operating properly. Toxic substances, laundry and cleaning supplies are inaccessible.

First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards.

There’s a centralized storage area for resident’s medication. The facility Medication Administration Record was reviewed as well as the dispensing log and was complete and current.

LPA reviewed 2 resident files and 1 staff file. Resident records reviewed had all the required documents and signatures. Staff records reviewed indicated current First Aid & CPR certificates. Facility is conducting staff training as required.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing later than October 1, 2021.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

LIC809 (FAS) - (06/04)

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