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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700326
Report Date: 08/02/2022
Date Signed: 08/29/2022 03:41:46 PM


Document Has Been Signed on 08/29/2022 03:41 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: 11DATE:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jessica QuistguardTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/2/22 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator 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, 11 resident bedrooms, bathrooms, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

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

Infection control Plan, Emergency Plan and Admin Cert are up to date.

LPA received a copy of Infection Control Plan and Liability Insurance by email.

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: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
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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