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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600438
Report Date: 05/18/2021
Date Signed: 05/18/2021 12:58:57 PM

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: 5DATE:
05/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:27 AM
MET WITH:Reyna EpsteinTIME COMPLETED:
01:00 PM
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On May 18, 2021 Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced annual required inspection. LPA met with Administrator, Reyna Epstein, and stated the purpose of the visit.

LPA toured the indoor and outdoor premises of the facility. The indoor and outdoor passageways were free of obstruction. LPA observed the resident bathrooms, and they are equipped with non-skid mats and grab bars. Bathroom is sanitary and odorless. The hot water temperature was measured in residents bathroom at 107 degrees Fahrenheit. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked in the cabinet located in the garage and inaccessible to residents. Food supply in kitchen, garage freezer, and pantry cabinet located in garage was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide, smoke detectors, and fire extinguisher were present at the facility. Centrally stored medication was locked in the kitchen cabinet and inaccessible by residents. All medication was labeled and sorted by resident name.

Staff records were reviewed. Staff have criminal record and fingerprint clearances on file. Staff have current First Aid/CPR certifications on file. Resident records were reviewed and were observed to be complete with documents such as Admission Agreements, Medical Assessments, and Needs and Service Plans.

No deficiencies observed today. Facility is operating in compliance with Title 22 regulations. This report was discussed with Administrator, Reyna Epstein, and a copy of this report was provided via email.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
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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