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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800187
Report Date: 11/25/2024
Date Signed: 12/23/2024 08:11:02 AM

Document Has Been Signed on 12/23/2024 08:11 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ROSE VALLEY REDLANDSFACILITY NUMBER:
361800187
ADMINISTRATOR/
DIRECTOR:		GLENN BERNALFACILITY TYPE:
740
ADDRESS:153 S DEARBORN STTELEPHONE:
(909) 389-7586
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 6CENSUS: 6DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:House Manager Mistie FeltonTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Sarina Ramirez and Becky Mann made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with House Manager Mistie Felton, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) with a current census of (6). LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: Indoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s bathrooms are equipped with grab rails and operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured between 106 to 111 degrees F. Resident’s bedrooms have sufficient lighting and bedroom furniture is in good repair. Facility has operating carbon monoxide alarms, laundry service, and telephone service. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster,personal rights, facility license, personnel report, resident roster, disaster evacuation plan and emergency telephone numbers.

Yards/Outside: Outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. The facility is enclosed with self-latching gates. Outdoor shaded area is sufficient for resident activities.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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 12/23/2024 08:11 AM - It Cannot Be Edited


Created By: Sarina Ramirez On 11/25/2024 at 11:37 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ROSE VALLEY REDLANDS
FACILITY NUMBER: 361800187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not associating S#1 to the facility through guardian which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2024
Plan of Correction
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Licensee has agreed to associate S#1 to facility through guardian 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:Karen Clemons
LICENSING EVALUATOR NAME:Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
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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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ROSE VALLEY REDLANDS
FACILITY NUMBER: 361800187
VISIT DATE: 11/25/2024
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Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Sharps, Disinfectants, and other cleaning solutions were kept locked and stored away inaccessible to residents in care..

Care & Supervision: Facility has 24-hour/7 days a week care staff. Staff working have criminal record clearances or exemptions through the Department.

Record Review: LPAs reviewed 6 resident files and 5 staff files. Licensee did not maintain a transfer of criminal record for S1, staff is not associated with the facility, deficiency will be issued. LPA observed facility's last emergency drill was conducted on 10/07/24

Medical Related Services: All medication is centrally stored, administered as prescribed and kept in a locked closet, inaccessible to residents in care.

Deficiencies were cited during today's visit and a plan of correction was discussed with facility representative, Mistie Felton.

An exit interview was conducted and copies of the licensing reports with appeal rights were provided to the House Manager Mistie Felton at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC809 (FAS) - (06/04)
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