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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600883
Report Date: 06/12/2024
Date Signed: 06/12/2024 11:14:08 AM

Document Has Been Signed on 06/12/2024 11:14 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ROSEL'S HOMEFACILITY NUMBER:
415600883
ADMINISTRATOR/
DIRECTOR:		ROMAR RAQUINIOFACILITY TYPE:
735
ADDRESS:2033 OREGON AVENUETELEPHONE:
(650) 387-9488
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 4CENSUS: 4DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee/Administrator - Romar RaquinoTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 06/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced infection control annual inspection. LPA met with administrator/licensee Romar Raquino and explained purpose of today's inspection. There are 3 staff present, the licensee Romar, and no clients as they are out at day program.

LPA was allowed entry into the facility. This is a single level facility. Annual Fees are current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored in the kitchen in locked cabinet adjacent to the sink. Perishable and non-perishable food items are observed as in place. There are additional refrigerators and freezers in the garage areas which also carry additional food supplies. LPA observed the medications as in place and locked in a closet adjacent to staff office and garage. First aid kit is observed as complete with required items. LPA observed that there are multiple fire extinguishers in place through out the facility last inspected on 05/15/2024, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. Facility is also equipped with fire pull alarms in two locations. One is centralized near the resident rooms and another near the dining room in a common hallway. PPE and additional food supplies are observed as in place. Laundry area is also observed as fully operational located in the garage area. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 105F in a resident bathroom. Bathtub and shower room floor is equipped with non-skid items. LPA observed all client rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place stored in a closet adjacent to resident rooms. Disaster drills take place monthly per records observed. Last taking place on 03/13/2024.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ROSEL'S HOME
FACILITY NUMBER: 415600883
VISIT DATE: 06/12/2024
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LPA reviewed 2 client files and also reviewed 4 staff files on this day. All files are current per review made. P&I is handled by the facility and current per the records reviewed. Client medications are inspected and are current including facility medication administration records. Administrator certificate is observed as current expiring on 12/23/2024.

The following updated forms are requested to be submitted to CCLD by 06/19/2024:

• Copy of updated Administrator Certificate
• Updated surety bond with expiration date
• LIC309 Administrative Organization
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC610D Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property such as lease agreement with expiration date

No citations issued. Report is reviewed with administrator/licensee Romar. Copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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