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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800187
Report Date: 11/23/2022
Date Signed: 11/23/2022 02:58:44 PM

Document Has Been Signed on 11/23/2022 02:58 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:ROSE VALLEY REDLANDSFACILITY NUMBER:
361800187
ADMINISTRATOR:GLENN BERNALFACILITY TYPE:
740
ADDRESS:153 S DEARBORN STTELEPHONE:
(909) 389-7586
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 6CENSUS: 6DATE:
11/23/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Iren CreightonTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Anna Bueno and Amber Coleman conducted an unannounced visit to subsequently investigate and deliver findings for complaint number: 18-AS-20201006151422. LPAs met with assistant administrator Iren Creighton who was explained the purpose of today’s visit.

During complaint investigation, records reviewed revealed that one of six residents have a Dementia diagnosis. This facility is not licensed to admit Dementia residents and this facility does not hold a dementia care plan. This poses an immediate health and safety risk to residents in care. Refer to LIC-809D for deficiency cited.

An exit interview was discussed with assistant administrator Iren Creighton. A copy of this report, LIC 809D, and appeal rights were provided to MS. Creighton.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2022
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 11/23/2022 02:58 PM - It Cannot Be Edited


Created By: Anna Bueno On 11/23/2022 at 01:41 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: ROSE VALLEY REDLANDS
FACILITY NUMBER: 361800187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/25/2022
Section Cited
CCR
87208(c)

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Plan of Operation - A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b).
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Licensee shall immediately place Resident 1 to another facility more appropriate for their level of care. Licensee shall notify the Department of this placement on or before the end of the POC date.
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This requirement was not met as evidenced by:

Resident 1 has a primary diagnosis of Dementia.
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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:Nedra Brown
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022


LIC809 (FAS) - (06/04)
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