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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600438
Report Date: 09/28/2020
Date Signed: 09/28/2020 11:19:51 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ROSE AMORFACILITY NUMBER:
415600438
ADMINISTRATOR:EPSTEIN, REYNAFACILITY TYPE:
740
ADDRESS:648 JOAQUIN DRTELEPHONE:
(650) 716-8022
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 6DATE:
09/28/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Reyna EpsteinTIME COMPLETED:
11:15 AM
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On 9/28/20 Licensing Program Analyst (LPA) Chris Hopkins conducted a case management inspection via facetime to inspect the facility for approval of Hospice Increase. LPA met with administrator Reyna Epstein and explained the nature of the tele-visit.

At 10:35am administrator Reyna Epstein gave LPA a tour of the facility, showing all 6 bedrooms, as well as kitchen, dining room, bathrooms, and garage. Bedrooms and bathrooms are in good standing. LPA also viewed food supply, which is adequate and PPE supply is adequate as well. LPA has requested documents to approve the Hospice increase, and administrator has agreed to send those to CCLD via fax.

No deficiencies cited.

LPA reviewed and discussed report with administrator Reyna Epstein. A copy of the report was sent via email for signature.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2020
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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