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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003893
Report Date: 05/09/2025
Date Signed: 05/09/2025 02:22:54 PM

Document Has Been Signed on 05/09/2025 02:22 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ROSEHAVEN 1FACILITY NUMBER:
306003893
ADMINISTRATOR/
DIRECTOR:		JAYALAKSHMI PICHIKAFACILITY TYPE:
740
ADDRESS:203 CALLE DEL JUEGOTELEPHONE:
(949) 366-2599
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY: 6CENSUS: 3DATE:
05/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Larry Espinal and Jaya PichikaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Rosehaven I. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, of which one may be bedridden. Facility has an approved hospice waiver for 5 residents and the home currently has 3 residents with none on hospice during today's visit. Administrator Jaya Pichika has a current administrator certificate expiring on 09/13/2025.
LPA Lyman along with Caregiver Larry Espinol toured the facility at 10:58 AM. Administrator Jaya Pichika arrived during the visit. LPA toured the physical plant, checked food service, reviewed records and the first aid kit. Facility appears to be clean, safe, and sanitary. The home consists of six resident bedrooms, one resident restroom, two common restrooms, one staff room, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed two residents with a half bed rails. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. At 11:05 AM, LPA observed there are missing drawer pulls in the master restroom. Water temperature measured between 109.4 and 111 degrees F in all facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. The entry door into the garage is secured. LPA observed a locked storage area for cleaning supplies. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. Four out of six smoke detectors are inoperable. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. CONT ON LIC809-C DATED 05/09/2025
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Kimberly Lyman
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ROSEHAVEN 1
FACILITY NUMBER: 306003893
VISIT DATE: 05/09/2025
NARRATIVE
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LPA toured the outside grounds and there is ample shaded seating for residents. At 11:15 AM, LPA observed the exit gate does not latch shut. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 04/25/2025 and drills are conducted quarterly. Facility provides activities in the form of exercise and games. At 11:30 AM, LPA reviewed three resident files and three staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Resident 2 does not have a current medical assessment in the file and two out of two residents with bed rails do not have a physician order for rails. One out of three staff do not have a personnel file and three out of three staff do not have current training. LPA reviewed medication storage and administration. Medications are stored in a locked cabinet and are being administered per physician order.


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.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Kimberly Lyman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2025 02:22 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 05/09/2025 at 12:31 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROSEHAVEN 1
FACILITY NUMBER: 306003893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed exit gate does not latch and the master restroom is missing drawer pulls on cabinets which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Please repair/ replace noted items and forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of three staff files. Staff 3 does not have a personnel file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Licensee to maintain a personnel file non Staff 3 and forward proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2025 02:22 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 05/09/2025 at 12:31 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROSEHAVEN 1
FACILITY NUMBER: 306003893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in three out of three staff without current training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Licensee to provide training and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2025 02:22 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 05/09/2025 at 12:31 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROSEHAVEN 1
FACILITY NUMBER: 306003893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)(1)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of three residents without an annual assessment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Licensee to obtain an annual assessment for Resident 2 and forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87608(a)(3)
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of two residents with bed rails did not have a written physician order for rails which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Licensee to obtain orders for Residents #2 and 3 and forward proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2025 02:22 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 05/09/2025 at 12:40 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROSEHAVEN 1
FACILITY NUMBER: 306003893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.


This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above in four out of six smoke detectors which did not work. This poses an immediate health, safety or personal rights risk to persons in care. CIVIL PENALTY ASSESSED
POC Due Date: 05/10/2025
Plan of Correction
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2
3
4
Licensee to repair/ replace smoke detectors and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
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