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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803637
Report Date: 09/17/2021
Date Signed: 09/22/2021 10:06:41 AM

Document Has Been Signed on 09/22/2021 10:06 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ROSEWOOD CRISIS RESIDENTIALFACILITY NUMBER:
486803637
ADMINISTRATOR:JOVAN YGLECIASFACILITY TYPE:
772
ADDRESS:508 ALABAMA STREETTELEPHONE:
(510) 415-4672
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 16CENSUS: 11DATE:
09/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:56 AM
MET WITH:Benjamin Blake, Chief of Clinical StrategyTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Chief of Clinical Strategy, Benjamin Blake. Administrator, Bjay Jones was out of the facility on leave during the time of visit but will be returning 9/20/2021. The facility currently provides care for 11 clients all of which were present during the time of visit with 1 additional client to be admitted to the program today.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. LPA measured water temperature at faucets accessible to clients. Water temperature measured between 110.1 and 117.3 degrees F, which is within regulation between 105 and 120 degrees F. Multiple fire extinguishers were located throughout the facility and all found to be last charged on 1/7/2021 at the time of the visit. There was a sufficient supply dishes, silverware and both perishable and nonperishable foods as required by Title 22 Regulations.

Toxins are stored in a locked cabinet in the facility laundry room, offices and supply closets located throughout the facility. There was a supply of hygiene products and paper products available and kept in facility offices. All client bedrooms have lighting & appropriate furnishings. Smoke detectors and carbon monoxide detectors located in facility hallways were tested and found to be in working order. The downstair secured basement area previously utilized for client one-on-one program is currently not in operation and is used for staff storage. LPA found that the doorknob for 1 of 2 exits in the basement is damaged and requires replacement. LPA conducted a sample review of staff training and found that all staff have current CPR and 1st Aid certification.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: ROSEWOOD CRISIS RESIDENTIAL
FACILITY NUMBER: 486803637
VISIT DATE: 09/17/2021
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Infection Control:
Facility has submitted a mitigation program plan which has been reviewed. All clients and staff are vaccinated with no symptoms. No surveillance testing is conducted as over 70% of staff and clients are vaccinated. Posters have been placed at the front door, and facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. Visitation areas are located in the facility staff office, the front porch and backyard. Staff and clients are screened for temperature and symptoms on a daily basis.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC809 (FAS) - (06/04)
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