Rose Cottage Rcfe

On 02/25/2026 at 3:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregivers, Apollo and Anthony McKarson and explained the purpose of the visit. Apollo phoned the Administrator, Lisa Bermudez and Licensee, Mynette Boykin, to inform. Ms. Bermudez and Ms. Boykin arrived to the facility shortly. The facility’s fire clearance was approved for six (6) residents in which all may be non-ambulatory. In addition, one (1) bedridden and an approved hospice waiver for two (2) residents. Administrator Certificate #6071393740 expires 07/29/2026. LPA toured facility with Apollo including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of seven (7) total bedrooms which six (6) bedrooms are occupied by the residents and one (1) bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. LIC809-C Continued... 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 26 27 28 29 30 31 32 LIC809-C (Page 2) Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 02/2026. Emergency Disaster Plan was last posted on 02/24/2026. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 10/02/2025. LPA reviewed three (3) residents records. LPA reviewed seven (7) staff records and five (5) of seven (7) have current first aid training and associated to the facility. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/04/2026: LIC 308 Designation of Administrative Responsibility - Reviewed LIC 309 Administrative Organization - Reviewed Updated LIC 500 Personnel Report - Reviewed LIC 610E Emergency Disaster Plan - Reviewed Liability Insurance - Reviewed No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 04/23/2025 at 10:25 AM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Plan of Correction (POC) visit and met with Caregiver, Apollo McKarson. LPA explained the purpose of the visit to Apollo. Apollo phoned the Licensee, Mynette Boykin to inform. LPA spoke with Licensee to explain the purpose of the visit. Licensee, stated that Administrator was not available but they would arrive to meet at the facility. Mynette arrived shortly. LPA conducted an Annual Inspection visit on 03/19/2025. The POC due date for cited deficiencies were 04/08/2025. The Licensee requested and extension to the due date which was granted to 04/18/2025. LPA did not receive the POCs on due date. Licensee shared emails between them, the resident's authorized representative and primary care physician. LPA granted another extension to May 7th, 2025 for all POCs with documents to be submitted to CCLD. Facility has the following deficiency that was not cleared : 87463(a) 87623(b)(2) 87628(a) No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 11/07/2024 at 10:30am Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to Community Care Licensing Division (CCLD) on 07/30/2024. LPA met with Caregiver, Apollo McKarson and explained the purpose of the visit. Apollo called Licensee, Mynette Boykin and Administrator, Lisa Bermudez to inform. On 07/30/2024, CCLD received a Death Report from Administrator indicating that R1 passed away on 07/27/24. The death report did not state whether R1 was on hospice at the time of their passing. The death report indicated that R1 had a stroke in 2014, was paralyzed, kidney failure and high blood pressure. The death report further indicated that S1 went to check on R1 and found them not breathing and they called 911 and the family. LPA interviewed S1 that stated R1 was declining and that they called the family to inform but the family did not want to send their mother to the hospital. S1 stated that they tried to advise the family that R1's health was declining and that they should place R1 on hospice but the family refused. S1 further stated that they called 911 and told 911 emergency that the resident was declining but the family did not want R1 to go to the hospital. S1 stated that the 911 call representative stated to them if the family refuses to send R1 to the hospital that the family is the one responsible. S1 stated that R1 passed away the following day. LIC809-C (Next Page) 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 26 27 28 29 30 31 32 LIC809-C Continued (Page 2) LPA interviewed S2 over the phone and S2 stated that R1 had a stroke 10 years ago and just started rapidly declining. S2 stated that the family was putting R1 on hospice at the end. LPA requested copies of R1's physician's report, appraisal needs and services, MAR, doctors orders, care notes, copy of police report and a copy of death certificate. LPA spoke with S2 over the phone and S2 stated that they have R1's records at the office and that they can have the documents tomorrow. LPA advised S2 to fax/e-mail the documents to LPA later today, 11/07/24. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.

On 05/04/2023 at 11:28 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Renielle "Ren" Cunanan and explained the purpose of the visit. The Licensee, Mynette Boykin came out from another room in the facility. The facility’s fire clearance was approved for 6. LPA toured facility with Ren including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. The facility consists of 2 bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. (Continue on LIC809C...) 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 26 27 28 29 30 31 32 Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was purchased 03/08/23. Emergency Disaster Plan was last posted on 08/02/2022 . First aid kit was observed to be complete. Emergency disaster drill was last conducted on 01/05/2023. LPA reviewed 5 of 5 residents records. LPA reviewed 6 staff records and 3 of 6 staff have current first aid training. All 6 staff are associated to the facility. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 05/11/2023: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate No deficiency cited during the visit. Exit interview conducted. Copy of this report provided.

On 2/18/2022 at 2:30 PM, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct the 3rd Pre-licensing inspection. LPA met with Applicant/Licensee, Mynette Boykin and explained the purpose of the visit. The facility currently has 6 residents because it's a changing of ownership. LPA toured facility, reviewed records of staff and residents, inspected four deficiencies cited on 2/4/22, and confirmed that deficiencies have been corrected. Component III Orientation had been conducted previously with Mynette Boykin by LPA Praveen Singh on 5/21/2021, therefore it's waived at this time. No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required. Exit interview conducted with Administrator and a copy of this report provided.

On 2/4/2022 at 10:25 a.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct the 2nd Pre-Licensing inspection. LPA met with Caregiver Apollo Mckarson and explained the purpose of the visit. Both facility Licensee and Administrator were unavailable during inspection. Licensee Mynette Boykin authorized caregiver Apollo to give tour to LPA and sign on report. The facility currently has 6 residents including 4 non-ambulatory and 2 ambulatory. LPA toured facility including but not limited to 6 bedrooms, 2 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 72 degrees F and hot water temperature was maintained at 113 degrees F. First-aid kit was observed to be complete. Smoke detector and Carbon monoxide were operational. Fire extinguisher was last serviced in Feb 2021. Prior to licensure, the following shall be corrected and faxed to CCL by 2/18/2022. Centrally stored medication was unlocked, in-services training is required. Centrally stored knives was unlocked, in-services training is required. Staff personnel records are required to be completed Used needles were disposed in a opened plastic bag, a secured container for disposed needles is required. Continue on LIC809-C 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 26 27 28 29 30 31 32 Issues were noted during inspection. LPA observed that facility is not ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required. Component III was not conducted at this time due to absence of Licensee and Administrator. Exit interview conducted with Caregiver, and a copy of this report provided.

Licensing Program Analyst (LPA) Praveen Singh continued a Pre-licensing Inspection initiated on 5/7/21. Due to the Governor's present shelter in place order, this inspection was completed via phone conference with Applicant/Administrator Mynette Boykin. LPA conducted a complete Pre-Licensing inspection and a Comp III Review with Applicant/Administrator on 5/7/21. LPA observed the facility was ready to be licensed with the exception of a matter concerning the facility's Fire Clearance. On 5/7/21, the Fire Department reissued a Fire Clearance for a capacity of five (5) non-ambulatory and one (bedridden). LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required. Exit interview conducted and a copy of this report provided via email. .

While at the facility conducting a Pre-Licensing inspection, Licensing Program Analyst (LPA) Praveen Singh conducted a Component III Orientation with Applicant/Administrator Mynette Boykin. Due to the Governor's present shelter in place order, this inspection was completed via phone-conference. The Applicant/Administrator was provided with information to operate the facility within Title 22 regulatory compliance, as well as how to avoid common problem areas. Component III does not cover ALL regulations, only those found to be most problematic. Regulations require Administrator to be knowledgeable of all regulations and amendments to law. Exit interview conducted and a copy of this report provided via email.