079201185-8-24-2023-15-AS-LHOS-CUZUF2-20230824153202

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201185
Report Date: 08/24/2023
Date Signed: 08/24/2023 03:32:12 PM

Document Has Been Signed on 08/24/2023 03:32 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:	ROSEWOOD RESIDENCE LLC		FACILITY NUMBER:	079201185
ADMINISTRATOR:	HERBERT, HELEN		FACILITY TYPE:	740
ADDRESS:	7100 MANILA AVENUE		TELEPHONE:	(510) 778-9084
CITY:	EL CERRITO	STATE: CA	ZIP CODE:	94530
CAPACITY:	6	CENSUS: 6	DATE:	08/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Araceli Emerick, Administrator (ADM)		TIME COMPLETED:	03:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/24/23 at around 01:30 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection. LPA was greeted by one staff upon entry and explained the purpose of the visit. The Administrator, Araceli Emerick (ADM) holds a standard certificate (#6047865740) exp. 04/10/24. The facility’s fire clearance was approved for six (6) non-ambulatory residents; one (1) may be bedridden. Facility has an Infection Control Plan (ICP). LPA observed a screening station at the entry that contained a thermometer, hand sanitizer, masks, face shields, gowns, gloves, COVID-19 signage, and a visitor sign-in log. LPA toured the facility including but not limited to common areas, bathroom, kitchen, garage, and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. Medication and sharps were locked, and there was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and garbage cans. There is a surplus of PPE centrally stored inside the facility that is accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 109.9 degrees Fahrenheit (F) and the facility's temperature was 78 degrees (F). First aid kit complete. Continued on LIC809C...

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ROSEWOOD RESIDENCE LLC	FACILITY NUMBER: 079201185
	VISIT DATE: 08/24/2023

NARRATIVE

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...continued from LIC809.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full. Emergency Disaster Plan is updated. Safety drills were last conducted 05/26/23 and are rotational quarterly.

LPA reviewed five (5) staff records, and all staff have criminal record clearances. Five (5) residents records were reviewed and are complete.

The following forms are to be updated and submitted to CCLD:
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s)

Exit interview conducted and a copy of this report provided to Araceli Emerick, Administrator (ADM).

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC809 (FAS) - (06/04)

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