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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426422
Report Date: 12/14/2022
Date Signed: 12/14/2022 02:11:42 PM

Document Has Been Signed on 12/14/2022 02:11 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:MORGAN E. WILLIAMSFACILITY TYPE:
740
ADDRESS:1350 WABASH AVE.TELEPHONE:
(909) 794-1040
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY: 63CENSUS: 60DATE:
12/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:53 PM
MET WITH:Morgan Williams administratorTIME COMPLETED:
02:30 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
 On 8/03/2022 Licensing Program Analyst (LPA) Bernadette Allen was at the facility to initiate a complaint investigation CONTROL NUMBER 56-AS-20220715164531
On 12/14/2022 LPA Allen arrived at the facility to amend a complaint investigation the LIC-9099 was updated and signed by Morgan Williams.

No deficiencies were cited at the time of visit.

An exit interview was conducted where this report was discussed and signed. A copy was provided at the conclusion of the visit.




SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2022
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 1