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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426422
Report Date: 05/03/2022
Date Signed: 05/03/2022 12:55:44 PM

Document Has Been Signed on 05/03/2022 12:55 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 GARDEN RESIDENTIAL CAREFACILITY NUMBER:
366426422
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:1350 WABASH AVE.TELEPHONE:
(909) 794-1040
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY: 63CENSUS: 59DATE:
05/03/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Morgan WilliamsTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced case management visit for a Health & Safety check in conjunction with complaint #
56-AS-20220429162510. LPA met with executive director (ED), Morgan Williams, who was explained the nature of the visit and granted entry to LPA.

LPA and ED toured the facility inside and out. LPA and ED observed seated residents in the dining hall and residents participating in the activities room. LPA and ED observed outdoor and indoor passageways were kept free of obstruction. During this visit, LPA did not observe imminent health & safety concerns.

A deficiency is being cited for reporting requirements. Refer to LIC-809D for deficiency. An exit interview was conducted where this report, LIC-809D, and appeal rights were discussed and provided to the ED Morgan Williams.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2022
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 05/03/2022 12:55 PM - It Cannot Be Edited


Created By: Anna Bueno On 05/03/2022 at 11:54 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
, CA 92507

FACILITY NAME: ROSE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 366426422

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2022
Section Cited
CCR
80061(b)(1)(B)

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(B) In a residential facility, death of any client...regardless of where the death occurred. This includes a death that occurred outside the facility such as at a day program, workshop, job, hospital, en route to or from a hospital, or visiting away from the facility.
This requirement was not met as evidenced by:
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Licensee submitted LIC 624A to LPA during today's visit.
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LPA verified that an LIC 624A was not submitted to the Department.
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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: 05/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2022


LIC809 (FAS) - (06/04)
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