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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609753
Report Date: 10/31/2022
Date Signed: 10/31/2022 04:08:50 PM

Document Has Been Signed on 10/31/2022 04:08 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ROSE SENIOR CARE INCFACILITY NUMBER:
197609753
ADMINISTRATOR:JEONG, SANDYFACILITY TYPE:
740
ADDRESS:18406 BLACKHAWK STTELEPHONE:
(818) 217-4955
CITY:PORTER RANCHSTATE: CAZIP CODE:
91326
CAPACITY: 6CENSUS: 6DATE:
10/31/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Sandy JeongTIME COMPLETED:
04:02 PM
NARRATIVE
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LPA Tihesha Smith conducted a case management deficiency visit today on 10/31/22 at 12:55 pm. LPA met with Licensee Sandy Jeong and disclosed the purpose of this visit.

On 07/29/22 LPA Smith received a phone call from Licensee requesting eviction information. The licensee also disclosed she has been having various issues with Resident One (R1). LPA inquired if any incidents reports have been sent to Department regarding past and current incidents involving R1 as LPA review of facility file did not uncover any new incidents. It was revealed during the conversation that R1’s toenail was removed and the Licensee did not report the incident or any incidents involving residents in care.

During this visit LPA interviewed Sandy at 1:05pm. It was revealed that R1’s toenail was infected (yellowing) and/or injured and the Licensee did not report the incident or any incidents involving residents in care. Licensee also revealed that R1 has moved out on 08/09/22 after meeting with R1 and R1 responsible party. LPA discussed with the Licensee reporting requirements and Licensee admitted she is not following reporting protocol.

Citations issued and recorded on LIC809D. Appeal rights discussed and given.



Exit interview conducted. Copy of this report issued
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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Document Has Been Signed on 10/31/2022 04:08 PM - It Cannot Be Edited


Created By: Tihesha Smith On 10/31/2022 at 03:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE SENIOR CARE INC
FACILITY NUMBER: 197609753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2022
Section Cited
CCR
87211

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Reporting Requirements (a)... licensee shall furnish to the licensing agency such reports as the Dept. may require, including, but not limited to, the following: (1) ... report shall be submitted to the... agency…within seven days of the occurrence…(B) Any serious injury.
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87211 Reporting Requirements; The written letter must be sent to the LPA by the POC due date 11/07/22
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occurring while the resident is under facility supervision. This requirement is not met as evidenced by: Based on interview and Licensee admitting facility did not report toenail infection/injury involving R1 to the Dept. which poses a potential Health and Safety risk to resident in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022


LIC809 (FAS) - (06/04)
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