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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294201
Report Date: 10/22/2021
Date Signed: 10/22/2021 01:57:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:ROSE GARDEN RCHFACILITY NUMBER:
445294201
ADMINISTRATOR:ORTIZ, CANDIEFACILITY TYPE:
740
ADDRESS:310 HATHAWAY AVENUETELEPHONE:
(831) 722-6346
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:6CENSUS: 5DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Candi RogersTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Candi Rogers Administrator.

LPA toured the facility inside and out to include the entry, bedrooms, bathrooms, kitchen, dining room, living room and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in locked cabinet in the kitchen. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products. Hand sanitizer available. LPA observed supply of Personal Protective Equipment (PPE).

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, sick leave polices, training, PPE usage and Fit Testing.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Candi Rogers Administrator and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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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