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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200299
Report Date: 11/27/2024
Date Signed: 11/27/2024 02:15:22 PM

Document Has Been Signed on 11/27/2024 02:15 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ROSE'S RESIDENTIAL CAREFACILITY NUMBER:
079200299
ADMINISTRATOR/
DIRECTOR:
MENJIVAR, ROSAFACILITY TYPE:
740
ADDRESS:2901 N. FRANCISCO WAYTELEPHONE:
(925) 864-7564
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:47 PM
MET WITH:Rosa Menjivar, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On 11/27/24 at 01:47PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit.

At 2PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 73 deg F. Hot water temperature was measured at 119 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguisher was observed fully charged and last inspected on 06/10/24. LPA reviewed 5 staff and 5 resident files.

Updated copies of the following documents were collected for facility file:
 LIC500- Personnel Report
 Resident Roster
 LIC308- Designation of Facility Responsibility
 LIC610E- Emergency/Disaster Plan including infection control plans
 Evidence of Liability Insurance

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
Bennett FongTELEPHONE: (510) 622-2621
Daisy PanlilioTELEPHONE: (510) 286-4201
DATE: 11/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2024
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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