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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425370
Report Date: 02/10/2023
Date Signed: 02/10/2023 03:51:20 PM

Document Has Been Signed on 02/10/2023 03:51 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 VILLAFACILITY NUMBER:
366425370
ADMINISTRATOR:MANZOOR R. MASSEYFACILITY TYPE:
740
ADDRESS:11906 KINGSTON STREETTELEPHONE:
(909) 825-7673
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY: 6CENSUS: 5DATE:
02/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Regina Albidriz, leadTIME COMPLETED:
03:55 PM
NARRATIVE
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On this day, Licensing Program Analysts (LPAs) Anna Bueno and Michelle Echeverria conducted an unannounced visit to this facility to continue investigation of complaint number: 56-AS-20230103155228 and deliver findings for complaint numbers: 56-AS-20220818142838 and 56-AS-20220721160710.

During the investigation number of complaint numbers: 56-AS-20220818142838 and 56-AS-20220721160710. Refer to LIC809-D for deficiency cited. Violation discovered are listed below:
    • Staff administration of suppository

An exit interview was conducted with and a copy of this report, LIC809-D, and appeal rights were provided to Janet Oliver.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE:
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE:
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 2
Document Has Been Signed on 02/10/2023 03:51 PM - It Cannot Be Edited


Created By: Anna Bueno On 02/10/2023 at 03:21 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 VILLA
FACILITY NUMBER: 366425370

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2023
Section Cited
CCR
87622(b)(1)

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(1) Ensuring that the administration of enemas or suppositories or manual fecal impaction removal is performed by an appropriately skilled professional should the resident require assistance.
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Licensee shall provide to the Department a memorandum of understanding of CCR section 87622. Proof shall be submitted to the Department no later than end of POC date.
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This requirement was not met as evidenced by:

LPA Bueno reviewed medication records showing that facility staff were administering suppositories.
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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: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023


LIC809 (FAS) - (06/04)
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