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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000176
Report Date: 02/04/2022
Date Signed: 02/04/2022 12:30:18 PM

Document Has Been Signed on 02/04/2022 12:30 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ROSE'S CARE HOMEFACILITY NUMBER:
397000176
ADMINISTRATOR:ROSITA IMBATFACILITY TYPE:
735
ADDRESS:1945 WOODCREST COURTTELEPHONE:
(209) 830-4312
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 6CENSUS: 6DATE:
02/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rosita Imbat - AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced 1 Year Required Annual /Infection Control visit on this date. LPA met with Rose Imbat, Administrator AD.
LPA and AD, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas.
LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured 108.3 degrees in residents bathroom with the AD which is in required range of 105 to 120 degrees.
Last Fire Drill conduced dated 1/30/2022. Fire extinguishers expire 3/10/2022.
Fire alarm and carbon monoxide functional.
LPA and AD observed centrally stored medications.
LPA reviewed 2 staff and resident files. Resident emergency contact complete. LPA observed all staff files complete.
Administrator Certificate expires 03/30/2023.
All persons in facility fully vaccinated. LPA observed resident practicing social distancing. LPA observed 30 days PPE supply.
LPA observed sharps and toxins locked.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, NO deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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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