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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005299
Report Date: 07/25/2024
Date Signed: 07/25/2024 12:39:14 PM

Document Has Been Signed on 07/25/2024 12:39 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:ROSEWOOD CARE HOMEFACILITY NUMBER:
306005299
ADMINISTRATOR/
DIRECTOR:		MALLARI, ANNAFACILITY TYPE:
740
ADDRESS:10821 VICKERS DRIVETELEPHONE:
(657) 667-0698
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 4DATE:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:53 AM
MET WITH:Narciso De GuzmanTIME VISIT/
INSPECTION COMPLETED:
12:53 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and William Vanegas for the purpose of conducting a Required – 1 Year Inspection. LPAs met with Staff #1 (S1) Narciso De Guzman and discussed the purpose of the inspection. Administrator (AD) Anna Mallari appeared via telephone.

LPAs reviewed Infection Control requirements. At about 10:15AM, LPAs and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 5-bedroom, 2-bathroom, one-story house with detached garage that is used for storage. There is a back yard with seating for the residents. LPAs observed 3 staff and 4 residents present at the facility. Resident Bedrooms: the 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPAs inspected the 1 staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 106 degrees F and 111 degrees in the 2 resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and laundry room. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 11:15AM, LPAs reviewed 4 resident files and 3 staff files, interviewed 2 residents and 2 staff, inspected medications for 4 residents, and inspected resident money and ledgers for 4 residents.

CONTINUED
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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 4
Document Has Been Signed on 07/25/2024 12:39 PM - It Cannot Be Edited


Created By: Sean Haddad On 07/25/2024 at 12:15 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: ROSEWOOD CARE HOME
FACILITY NUMBER: 306005299

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(h)(2)
Planned Activities
(h) Facilities shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas which are easily accessible to residents and protected from traffic. Gardens or yards shall be sufficient in size, comfortable, and appropriately equipped for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and admission, the facility does not have shaded outdoor seating for residents although the residents do engage in activities outside, which poses a potential personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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Licensee stated they will purchase and install shaded outdoor seating and submit proof to LPA by POC due date.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on documents, the facility has been using Regional Center admission agreements and does not have their own admission agreement executed with any of the 4 residents, which poses a potential personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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Licensee stated they will execute their own approved admission agreements with all 4 residents and submit 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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/25/2024 12:39 PM - It Cannot Be Edited


Created By: Sean Haddad On 07/25/2024 at 12:23 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: ROSEWOOD CARE HOME
FACILITY NUMBER: 306005299

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)


87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, 3 out of 5 smoke detectors tested were inoperable, which poses an immediate safety risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Licensee stated that they will replace or repair all inoperable smoke detectors and submit 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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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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ROSEWOOD CARE HOME
FACILITY NUMBER: 306005299
VISIT DATE: 07/25/2024
NARRATIVE
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During the inspection, LPAs and S1 observed the following: based on observation, 3 out of 5 smoke detectors tested were inoperable; based on observation and admission, the facility does not have shaded outdoor seating for residents although the residents do engage in activities outside; based on documents, the facility has been using Regional Center admission agreements and does not have their own admission agreement executed with any of the 4 residents.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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