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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604380
Report Date: 08/10/2022
Date Signed: 08/10/2022 02:01:52 PM

Document Has Been Signed on 08/10/2022 02:01 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ROSE GARDEN CAPOFACILITY NUMBER:
374604380
ADMINISTRATOR:CORPUZ, ROLANDOFACILITY TYPE:
740
ADDRESS:28688 MOUNTAIN MEADOW ROADTELEPHONE:
(760) 913-5199
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 6DATE:
08/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Janet MosterTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit to address a deficiency discovered during the processing of the facility's annual inspection.
Facility staff phoned Licensee/Administrator Bobby Corpuz to notify him of LPA's presence in the facility. LPA spoke with Corpuz via telephone. Corpuz was unable to return to the facility, but did send house manager Janet Moster from the sister facility, Rose Garden.

During today's visit, LPA interviewed Staff #1 (S1), reviewed documents in S1's file, and interviewed Corpuz via telephone. LPA discovered that in 2017, S1 had been excluded from being employed by any licensed facility of the Department of Social Services (DSS), being present in any licensed facility of the Department of Social Services, and having contact with any resident of a facility licensed by the Department of Social Services for the remainder of his life. On August 9, 2022, S1 was observed to be employed at the facility and subsequently caring for residents during the facility's annual inspection. During today's visit, LPA requested S1 leave the facility immediately to which he complied and LPA observed him vacate the property via Uber shortly thereafter. Licensee/Administrator Bobby Corpuz was educated of the 2017 public Decision and Order regarding the prohibition of S1's presence in ANY licensed facility. S1 may petition DSS for reinstatement and may only return to any licensed facility if and when the petition is approved/granted. Licensee Corpuz acknowledges S1 may not be present in any licensed facility until such petition is approved/granted and stated S1 will not be allowed to return until then. A copy of the public Decision and Order was provided to the facility as well.

There are no health, safety, or personal rights concerns noted at the facility at this time.

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 this reported was provided along with appeal rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2022
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 08/10/2022 02:01 PM - It Cannot Be Edited


Created By: Tricia Danielson On 08/10/2022 at 10:21 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
RIVERSIDE, CA 92507

FACILITY NAME: ROSE GARDEN CAPO
FACILITY NUMBER: 374604380

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2022
Section Cited
CCR
87412(a)(13)(A)

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Personnel Records- (a) The licensee shall ensure that personnel records are maintained on... each employee. Each personnel record shall contain...(13) For employees that are required to be fingerprinted...(A) A signed statement regarding their criminal record history as required by Section 87355(d). This requirement was not met as evidenced by:
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Licensee agrees to complete LIC508 for all employees and/or prospective employees and a copy of such form will be maintained in facility records. Proof of completion of LIC508 for S1 will be sent to LPA by 8/15/2022 and maintained in facility records.
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The licensee did not ensure S1 completed form LIC508 prior to employment and a copy of this form was not stored in the file of S1. This poses an potential health, safety, and personal rights risk to residents 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:Tricia Danielson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022


LIC809 (FAS) - (06/04)
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