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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604117
Report Date: 01/11/2023
Date Signed: 01/11/2023 12:00:13 PM

Document Has Been Signed on 01/11/2023 12:00 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'S CANYON VIEW ESTATEFACILITY NUMBER:
374604117
ADMINISTRATOR:PARAISO, CATHERINE TFACILITY TYPE:
740
ADDRESS:2644 CANYON RDTELEPHONE:
(760) 739-0311
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 6CENSUS: 3DATE:
01/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:LEAD CAREGIVER, MIREILLE KIFUMBI. TIME COMPLETED:
12:08 PM
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On January 11, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection with focus on infection control. LPA Mixson met with Lead Caregiver introduced self and advised of the purpose of the visit.

Present in the facility were three residents and one staff. Currently there are no cases of COVID-19 within the facility.

LPA Mixson observed residents have hand sanitizer available to them, and all restrooms were stocked with liquid soap and paper towels. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions and the proper use of face coverings.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, and cleaning and disinfection provisions are in adequate quantities. LPA Mixson later discussed infection control practices and procedures with Lead Caregiver.

An exit interview was conducted and a copy of this report, along with the LIC 811, was provided to Lead Caregiver.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2023
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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