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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003893
Report Date: 07/29/2022
Date Signed: 07/29/2022 09:58:54 AM

Document Has Been Signed on 07/29/2022 09:58 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: 5DATE:
07/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Brenda CastilloTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20220705085643. LPA was greeted and granted entry into the facility by Caregiver Brenda Castillo and explained the reason for the visit. Administrator/ Licensee Jay Pichika arrived during the visit.

During the course of the complaint visit, LPA met with Staff 1 (S1). S1 indicates working at facility for a week. LPA observed through Guardian and LIS that S1 is not associated to the facility.







Based on the observations made during today's visit, the following violation is 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: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2022
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 07/29/2022 09:58 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 07/29/2022 at 09:10 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: 07/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2022
Section Cited
CCR
87355(c)

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A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: This requirement is not being met as evidenced by:
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Licensee to submit LIC 9182 or associate the staff in the Guardian system and forward proof to LPA by POC due date.
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Based on interview and record review, Licensee failed to ensure S1 is associated to the facility. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED
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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: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022


LIC809 (FAS) - (06/04)
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