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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700326
Report Date: 08/05/2021
Date Signed: 07/18/2022 04:08:20 PM


Document Has Been Signed on 07/18/2022 04:08 PM - It Cannot Be Edited

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:ROSEBERRY CAREFACILITY NUMBER:
342700326
ADMINISTRATOR:QUISTGUARD, JESSICAFACILITY TYPE:
740
ADDRESS:128 BERRY STREETTELEPHONE:
(916) 780-3369
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:15CENSUS: 7DATE:
08/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jessica QuistgardTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 85/21 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual 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 contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA met with Administrator to conduct an annual inspection infection control review.

LPA toured the interior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, 9 resident bedrooms,7 bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

Administrator arrived at the facility. LPA, Administrator who is Infection control Leader completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA requested for documents such as LIC 500, Administrator's Certificate, LIC 610E and Liability Insurance. Documents to be submitted to LPA via email by due date on, Mon 8/9/21.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021
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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