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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003893
Report Date: 11/23/2021
Date Signed: 11/23/2021 11:37:05 AM

Document Has Been Signed on 11/23/2021 11:37 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ROSEHAVEN 1FACILITY NUMBER:
306003893
ADMINISTRATOR:JAYALAKSHMI PICHIKAFACILITY TYPE:
740
ADDRESS:203 CALLE DEL JUEGOTELEPHONE:
(949) 366-2599
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY: 6CENSUS: 2DATE:
11/23/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Dominga Santillian and Jay PichikaTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 11/02/2021. LPA was greeted and granted entry into the facility by Caregiver Dominga Santillian and explained the reason for the visit. Administrator Jaya Pichika arrived during the visit.

*Deficiency cited under Title 22 Regulation 87211(a)(1)(A) pertaining to Reporting Requirements has been cleared. Administrator provided requested death report. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87303(a) pertaining to Maintenance and Operation has been cleared. LPA observed Licensee has repaired/ replaced noted items. Licensee has complied with the terms of the POC.

Advisory note issued on 11/02/2021 advised the following: Facility does not have the "Let Us No" poster in the facility at correct size. Please post in regulation size, 20" X 26" Facility has not posted the poster in regulation size.

During the tour of the facility, LPA observed live and dead cockroaches in the kitchen and in resident room.

Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2021
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 11/23/2021 11:37 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 11/23/2021 at 09:51 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROSEHAVEN 1
FACILITY NUMBER: 306003893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2021
Section Cited
CCR
87468(c)(2)(A)

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Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents...Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) ... The poster that is posted shall be 20" x 26" in size and be posted in the main entryway of the facility. This req is not being met as evidenced by:
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Licensee to post the poster in regulation size and forward proof to LPA by POC due date.
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Based on observation, Licensee failed to ensure the "Let Us No" poster is posted in the entrance of the facility in regulation size, 20" X 26." This poses a potential health and safety risk to residents in care.
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Type B
11/30/2021
Section Cited
CCR87307(d)(2)

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The following space and safety provisions shall apply to all facilities:
The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
This requirement is not being met as evidenced by:
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Licensee to repaire broken cupboards and exterminate cockroaches. Licensee to forward proof to LPA by POC due date.
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Based on observation, LPA observed live and dead cockroaches in the kitchen and resident bedroom. This poses a potential health and safety risk to residents 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2021


LIC809 (FAS) - (06/04)
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