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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201311
Report Date: 02/17/2022
Date Signed: 02/17/2022 04:41:42 PM

Document Has Been Signed on 02/17/2022 04:41 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ROSSMORE A.R.F. HOMEFACILITY NUMBER:
435201311
ADMINISTRATOR:HELEN V. CARRANZAFACILITY TYPE:
735
ADDRESS:2955 ROSSMORE LANETELEPHONE:
(408) 531-9487
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: DATE:
02/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:TIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced at the facility to conduct a case management visit and met with Maritess Sanchez, caregiver.

On 02/14/2022, LPA arrived unannounced to open a complaint investigation. During visit, LPA toured the facility to include the dining room, living room, kitchen, resident rooms, bathrooms and backyard.

On 02/14/2022 at 10:30 a.m., LPA observed a basket full of expired medications on the floor of the backyard. Caregiver immediately secured the basket full of expired medications in a locked storage area.

A deficiency was cited during visit on LIC9099D on 02/14/2022 per California Code of Regulations, Title 22. See LIC9099D on 02/14/2022.

An exit interview was conducted. LPA reviewed the report with Maritess Sanchez, caregiver and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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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