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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005575
Report Date: 04/08/2022
Date Signed: 04/08/2022 03:21:45 PM

Document Has Been Signed on 04/08/2022 03:21 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:ROSE GARDEN VILLAFACILITY NUMBER:
306005575
ADMINISTRATOR:OLTEANU, CLAUDIAFACILITY TYPE:
740
ADDRESS:2210 W AVALON AVETELEPHONE:
(949) 232-9619
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY: 6CENSUS: 6DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Caregiver Mylene Manze/ Adminstrator - Claudia Olteanu TIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA)Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Mylene Manze and explained the reason for the visit. At 2:03 PM Administrator Claudia Olteanu arrived during the visit. Claudia Olteanu has a current administrator certificate expiring on 06/13/2022.

At 1:35 PM, LPA toured the facility with Caregiver Mylene Manze. Facility is 7 bedroom, 3 bathroom single story home with an attached garage. Facility has 5 residents present during today's visit. LPA observed residents relaxing in the facility. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility uses a handwritten sign in/ questionnaire. Facility takes residents and staff temperatures daily and documents. The facility mitigation plan has been completed and approved. LPA observed 6 emergency food containers with 124 servings per container and 3 packs of 48-pack of water. LPA observed locked medication drawer. Fire extinguisher is mounted and charged. LPA toured the outside grounds and observed outside shaded visitation area. Exit gate is unlocked and self latching. Facility has a plan for covid testing resident and staff as needed as well as a plan for isolation. LPA observed a 4 weeks supply of PPE. All staff and residents are vaccinated for Covid-19. LPA reviewed all residents files and all contained required documentation including updated emergency information.


No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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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