397000176-2-27-2023-27-AS-APAA-CPFQDD-20230227110435

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397000176
Report Date: 02/27/2023
Date Signed: 02/27/2023 11:04:47 AM

Document Has Been Signed on 02/27/2023 11:04 AM - 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 HOME		FACILITY NUMBER:	397000176
ADMINISTRATOR:	ROSITA IMBAT		FACILITY TYPE:	735
ADDRESS:	1945 WOODCREST COURT		TELEPHONE:	(209) 830-4312
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY: 6		CENSUS: 5	DATE:	02/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Rose Imbat		TIME COMPLETED:	11:00 AM

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 02/27/2023 at 9:30am, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to conduct an annual visit. LPA Pascua was greeted by Facility Designated Administrator, Rose Imbat and explained the purpose of the visit. The purpose of this visit is to conduct an annual visit. The Facility Designated Administrator currently holds an active certificate #6025575735 and expires on 03/30/2023. This facility is licensed to hold 6 residents who are deemed to be ambulatory only. This facility is also vendorized by Valley Mountain Regional Center to hold Level 2 residents at this time. There were two other staff members present, Joel Encinta and Stephanie Imbat. Current census was 5. A tour of the facility was initiated with FDA Imbat. The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been purchased on 05/11/2022. The facility has a centralized screening point at the front of the facility and holds a 30-day supply of PPE. The kitchen area was toured. LPA observed a sufficient seven days of non-perishable foods as well as two days worth of perishable food supplies in the main kitchen. Additional perishable and non-perishable food supplies were identified in the garage. Knives were observed to be locked in a kitchen cabinet and made inaccessible to the residents at this time. LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with a staff member, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components. A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time. A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time. Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 397000176
	VISIT DATE: 02/27/2023

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A tour of the garage was conducted. Additional non-perishable food supplies were identified. All cleaning supplies were locked and made inaccessible to residents at this time.

The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies are being cited today in violation of California Code of Regulations.

An exit interview was conducted, a copy of the LIC 809 and LIC 809-C was provided to the facility at the end of the visit.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

LIC809 (FAS) - (06/04)

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