374604115-1-28-2026-18-AS-JROO-DQRSN6-20260128130101

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604115
Report Date: 01/28/2026
Date Signed: 01/28/2026 01:01:09 PM

Document Has Been Signed on 01/28/2026 01:01 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	COUNTRY ROSE ESTATE MEMORY CARE		FACILITY NUMBER:	374604115
ADMINISTRATOR/ DIRECTOR:	PARAISO, CATHERINE T		FACILITY TYPE:	740
ADDRESS:	1255 ADVENTURE LN		TELEPHONE:	(760) 738-9391
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92069
CAPACITY: 15		CENSUS: 15	DATE:	01/28/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:20 AM
MET WITH:	Administrator Val Paraiso		TIME VISIT/ INSPECTION COMPLETED:	01:10 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 01/28/2026, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Val Paraiso who was informed of the purpose of the visit. The facility is licensed to serve fifteen (15) non-ambulatory elderly residents and is approved for a secured perimeter. The facility also has an approved hospice waiver for six (6) residents and LPA was informed only one (1) resident is currently receiving hospice services at the facility. LPA toured the facility's interior and exterior with Administrator Paraiso. During the tour, LPA observed the facility is made up on a one-story building with eleven (11) resident bedrooms, two (2) showers, a kitchen, dining room, living room, and laundry room. LPA observed four (4) staff present in the facility. LPA conducted a record review and all four (4) staff present have a criminal record clearance and are associated with the facility. Resident bedrooms had the required bedding, furniture and lighting. Showers were equipped with grab bars and non-skid mats. LPA toured the kitchen and observed the facility has more than a two-day supply of perishable foods and seven-day supply of non-perishable food items. Knives are secured in a locked kitchen cabinet. Medications are secured in a locked cabinet inside the administrator's office. Disinfectants and cleaning solutions are secured in the locked laundry room. No bodies of water were observed on the premises. Indoor and outdoor passageways were free of obstruction. The outside area provides shaded seating available for resident use. Administrator tested one (1) of the smoke alarms/carbon monoxide detectors and LPA heard it to be operational. LPA also observed several charged fire extinguishers mounted throughout the facility that were last serviced on 09/11/2025.

NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Janette Romero
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COUNTRY ROSE ESTATE MEMORY CARE	FACILITY NUMBER: 374604115
	VISIT DATE: 01/28/2026

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Administrator reported they submitted a capacity increase request to Community Care Licensing and the San Marcos Fire Department (SMFD) has required the facility's driveway to be paved in order to facilitate fire department apparatus' access to the facility. Administrator added SMFD has allowed them to pave the facility's driveway by 2027 due to the financial cost of the project. LPA reviewed the facility's annual fire inspection dated 05/09/2024 conducted by SMFD noting the facility was cited for not having illuminated exit signs or a five (5) year fire sprinkler certification. During today's visit, LPA observed all exit signs to be illuminated and an inspection tag noting the facility's five (5) year sprinkler certification was completed in February of 2025. Residents' personal rights, complaint procedures, Long-Term Care Ombudsman's contact information, emergency disaster plan and facility sketch are visible posted near the front entrance. No issues or concerns were observed during today's visit. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Paraiso.

NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Janette Romero
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

LIC809 (FAS) - (06/04)

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