<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003893
Report Date: 11/23/2021
Date Signed: 11/23/2021 11:40:39 AM

Document Has Been Signed on 11/23/2021 11:40 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Dominga Santillian and Jay PichikaTIME COMPLETED:
12:05 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
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident report submitted to Community Care Licensing on 11/17/2021. LPA was greeted and granted entry into the facility by Caregiver Dominga Santillian and explained the reason for the visit. Administrator/ Licensee Jay Pichika arrived during the visit.

Incident report dated 11/17/2021 indicated Resident 1 (R1) was taken to the urgent care due to possible UTI and Depakote overdose. Administrator stepped out of urgent care for a zoom meeting. Urgent care determined R1 needed to be seen at the emergency room and was unsuccessful in reaching the administrator. Per witnesses, urgent care reached out to facility staff as well as responsible party to advise of the situation. Administrator states being unable to answer phone due to the administrator's zoom call. Administrator made contact after the zoom call and R1 was sent to the emergency room. R1 was diagnosed with a urinary tract infection. R1's levels of Depakote were deemed to be acceptable and facility continues to follow the medication orders on file as responsible party is in contact with physician to change the order to a lower dose. Witnesses interviewed indicate R1 is currently incontinent and incontinence care is not being provided at night.



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)
Page: 1 of 2
Document Has Been Signed on 11/23/2021 11:40 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 11/23/2021 at 10:48 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 A
11/24/2021
Section Cited
CCR
87464(f)(1)

1
2
3
4
5
6
7
Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
1
2
3
4
5
6
7
Licensee to submit a statement indicating understanding of care and supervision and forward proof to LPA by POC due date.
8
9
10
11
12
13
14
Based on interviews conducted, Licensee failed to ensure R1 was provided care and supervision. Licensee was unable to receive urgent care's calls due to an appointment Administrator was on. R1 was being transferred to the emergency room. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
12/07/2021
Section Cited
CCR87468.1(a)(1)

1
2
3
4
5
6
7
Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not being met as evidenced by:
1
2
3
4
5
6
7
Licensee to submit a written plan indicating how incontinence care will be provided and forward proof to LPA by POC due date.
8
9
10
11
12
13
14
Based on interviews conducted, Licensee failed to ensure incontinence care is being provided as needed. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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)
Page: 2 of 2