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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804074
Report Date: 09/22/2022
Date Signed: 09/22/2022 07:34:30 PM

Document Has Been Signed on 09/22/2022 07:34 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ROSE RENEE RESIDENTIAL CARE FACILITYFACILITY NUMBER:
486804074
ADMINISTRATOR:FRASIER, FELICIAFACILITY TYPE:
735
ADDRESS:1220 SERENO DRTELEPHONE:
(707) 980-6830
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 4CENSUS: 0DATE:
09/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Felicia FrasierTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Araceli Canela conducted a pre-licensing inspection on 9/22/2022. This is a single story home, with 3 bedrooms that will be used for clients, 1 bathrooms, living room, dining room, kitchen, two hallway closets and garage.
LPA met with applicants Anthony and Felicia Frasier who will be the Administrator once the facility is approved for licensure. The facility received a fire clearance approval from the Vallejo Fire Department on 6/20/2022 for a total of 4 ambulatory clients. Facility will operate with 24 hour staffing and Licensee will ensure sufficient staffing at all times clients are in care.

During today’s visit LPA observed the following items:
  • Lockable cabinets for medication and client files.
  • Toxins/cleaners are stored in locked cabinet in garage and knives are locked in closet cabinet.
  • 4 smoke detectors & carbon monoxide detector, were tested and observed operational. All exits were unobstructed.
  • Complete first Aid kit and flashlights for emergency lighting are available.
  • 2 Fire Extinguisher were charged and serviced on 4/20/2022.
  • Supply of linens, paper products, and hygiene supplies available
  • Required furnishings in all 3 bedrooms that include, bed, night stand, lamp, chair, dresser and required linens.
  • Administrator Certification; Required postings (Personal Rights, Emergency plan/numbers, and visitor policy).
  • Water temperature was tested during inspection (112F) and was within regulation of 105-120 Degrees F.

The Component III Orientation was completed with applicants Anthony and Felicia Frasier.

LPA will submit the pre-licensing report to the Application Unit Analyst in Sacramento; "Pre-licensing is complete and this facility has no deficiencies"

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
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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