342700326-8-9-2023-59-AS-IAVA-CUJSTR-20230809140957

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700326
Report Date: 08/09/2023
Date Signed: 08/09/2023 02:10:07 PM

Document Has Been Signed on 08/09/2023 02:10 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	ROSEBERRY CARE		FACILITY NUMBER:	342700326
ADMINISTRATOR:	QUISTGUARD, JESSICA		FACILITY TYPE:	740
ADDRESS:	128 BERRY STREET		TELEPHONE:	(916) 780-3369
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95678
CAPACITY:	15	CENSUS: 12	DATE:	08/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Jessica Quistgard		TIME COMPLETED:	02:30 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 08/9/2023 Licensing Program Analysts (LPAs) Ivan Avila and Kevin Mknelly arrived at the facility unannounced to conduct a 1-year annual inspection and met with Administrator Jessica Quistgard and explained the purpose of the visit. Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Physical Plant & Environment Safety: There are nine (9) bedrooms, seven (7) bathrooms, a living room, dining room, kitchen, front yard, and backyard. The LPAs observed resident bedrooms furnished with at least one night stand, bed and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. The LPAs observed the resident’s bathroom to be clean, and properly supplied. Hygiene products are readily available for clients in care. There were no obstructions and/or tripping hazards throughout the facility. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. There are no security bars or weapons on the premises. The hot water temperature was tested bathrooms and measured within the required range of 105-120 degrees. There is a designated storage area for cleaning solutions, toxins, knives, and hazardous items are stored in a locked cabinet and are inaccessible to clients. Food Service: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. Sharp objects are stored in a locked room. LPAs observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.

LPAs reviewed a total of five (5) residents' files and five (5) staff files.

Several topics were discussed. There are no deficiencies being cited at this time. An exit interview was held, and a copy of the report was provided to Administrator.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 895-5033
LICENSING EVALUATOR NAME: Ivan Avila	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 1