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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604117
Report Date: 04/14/2023
Date Signed: 04/14/2023 01:09:15 PM

Document Has Been Signed on 04/14/2023 01:09 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: 5DATE:
04/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Val Paraiso, AdministratorTIME COMPLETED:
01:20 PM
NARRATIVE
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On April 14, 2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced to the facility to conduct a case management visit in conjunction with complaint18-AS-20230411130033. LPA met with Administrator, Val Paraiso who was informed of the purpose of the visit.

At the time of visit, LPA conducted an inspection of the facility and observed Val Paraiso’s Administrator certificate expired on 5/21/2022. Val Paraiso stated Administrator has not taking some classes but is still working on renewing the certificate. Citation will be issued.

LPA was informed Resident #1 has wandered off of the facility several times, but the incident was not reported to the department. Citation will be issued.

Therefore, based on the observations made during today’s visit, the following deficiency was cited per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted, and a copy of this report was reviewed with and provided along with appeal rights to Val Paraiso.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2023
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
Document Has Been Signed on 04/14/2023 01:09 PM - It Cannot Be Edited


Created By: Chinwe Nwogene On 04/14/2023 at 12:16 PM
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
RIVERSIDE, CA 92507

FACILITY NAME: ROSE'S CANYON VIEW ESTATE
FACILITY NUMBER: 374604117

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2023
Section Cited
CCR
87407(e)

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Administrator Recertification Requirements;

To apply for recertification after the expiration date of the certificate, but within four (4) years of the certificate expiration date, the certificate holder shall submit to the Department’s Administrator Certification Section:

(1) A completed Application for Administrator Certification form LIC 9214.
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Administrator stated the required clasess will be completed with in the next 10day and the Administrator packet will be mailed out by POC due date.
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This requirement is not met based as evidence by observation, interview, and record review. The licensee did not comply by not renewing Administrator certificate which poses a potential health, safety or personal rights risk to persons in care.
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Type B
04/24/2023
Section Cited
CCR87211(a)(1)(d)

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Reporting Requirements;
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

Any incident which threatens the welfare, safety or health of any resident,
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Administrator stated moving forward all incidents will be reported to the department.
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This requirement is not met based as evidence by interview. The licensee did not comply by not reporting to the department that R1 wandered off of the facility which poses a potential health, safety or personal rights risk to persons in care.
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023


LIC809 (FAS) - (06/04)
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