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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700403
Report Date: 01/28/2022
Date Signed: 01/28/2022 11:59:02 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 CAREFACILITY NUMBER:
312700403
ADMINISTRATOR:LOPEZ, DOINAFACILITY TYPE:
740
ADDRESS:6130 EAGLECREST WAYTELEPHONE:
(916) 872-1837
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:6CENSUS: 6DATE:
01/28/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Doina Lopez, AdministratorTIME COMPLETED:
12:30 PM
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mon areas were cleaOn January 28, 2022, 11:30am Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived to conduct a Required Annual Inspection. LPA met with Doina Lopez the Licensee, and informed him of the reason for the visit. Prior to the inspection, LPA completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19, contacted licensee 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 staff upon arrival.

Doina and LPA completed the inspection tool questionnaire with no issues or advisories to report.

LPA observed the following:
Administrator certificate is valid. First aid kit fully stocked and ready for emergency use. Fire extinguishers fully charged. Facility temperature measured 77 degrees F. Hot Water temperature measured 107 degrees F.
Comn and in good repair. Bedrooms had required furniture and lighting. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. Medication was properly stored and locked away.

As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6.

The administrator submitted an 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 our Regional Office on 9/28/2021.

Exit interview conducted and a copy of this report given to Doina.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
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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