<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426422
Report Date: 11/24/2021
Date Signed: 11/24/2021 12:28:55 PM

Document Has Been Signed on 11/24/2021 12:28 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
RIVERSIDE, CA 92507
FACILITY NAME:ROSE GARDEN RESIDENTIAL CAREFACILITY NUMBER:
366426422
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:1350 WABASH AVE.TELEPHONE:
(909) 794-1040
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY: 63CENSUS: 57DATE:
11/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Morgan WilliamsTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Anna Bueno and Bernadette Allen conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on the infection control domain. LPA met with Administrator-Morgan Willians and Wellness Director- Cindell Graham who confirmed there are no active and/or suspected Covid-19 cases in the facility.

The facility has a single-entry point to the main lobby and has a sign-in policy for universal entry screening. The facility also documents daily temperature and COVID-19 symptom checks for all visitors while residents are subject to routine symptom screening and regular observations for any change in condition. LPA observed all staff are properly fitted with face coverings. Continued weekly routine testing for staff is still observed.

LPA Anna Bueno, Bernadette Allen, Williams, and Graham toured the facility inside and out. Morgan confirmed that the fire clearance inspection was issued 9/8/2021. Fire alarms and fire extinguishers are maintained and monitored by an outside vendor. LPA’s viewed a fire extinguisher tag showing that last inspection date of 9/1/2021. Hand sanitizer dispensers were observed throughout the facility. LPA’s confirmed the facility has an adequate supply of cleaning and disinfectant provisions.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ROSE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 366426422
VISIT DATE: 11/24/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy of this report was also provided to the Administrator at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2