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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604380
Report Date: 08/26/2024
Date Signed: 08/26/2024 12:21:38 PM

Document Has Been Signed on 08/26/2024 12:21 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:ROSE GARDEN CAPOFACILITY NUMBER:
374604380
ADMINISTRATOR/
DIRECTOR:		CORPUZ, ROLANDOFACILITY TYPE:
740
ADDRESS:28688 MOUNTAIN MEADOW ROADTELEPHONE:
(760) 913-5199
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 5DATE:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:13 AM
MET WITH:Rolando Corpuz, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 08/26/24 at 9:13am Licensing Program Analyst (LPA) Javina George made an unannounced visit tot he facility to conduct a 1 year required inspection. LPA was greeted and granted entry by Caregiver Perla Sterment, LPA explained the purpose of the visit. Rolando Corpuz, Administrator arrived at 9:55am.

LPA conducted a tour of the interior and The facility is a single story home consisting of 5 bedrooms, 3 bathrooms, kitchen, living room, a pool and spa, pool house and shed that is being utilized for storage. The facility was observed to be clean, clutter, and free from obstructions in the passageways. The facility was observed to have personal protective equipment (PPE) supplies. The medications were observed to be locked and inaccessible to residents in care, and to be given as prescribed. There are no known guns or ammunition on the premises. The facility was observed to have multiple smoke and carbon monoxide detectors that were tested and observed to be operable. There was one detector that needs to have the batteries changed, however it was too high to reach, and there was no ladder available at the time of the visit. As discussed and agreed with Administrator Rolando, the batteries will be replaced by 5pm on 08/27/24. The facility has no record of emergency disaster drills being conducted on a quarterly basis. Deficiency cited.

LPA conducted a review of resident files and observed for the required documentation to be present. Staff record review, all staff present were observed to have obtained criminal record clearance and to be associated to the facility. The staff files were observed to have no updated training, such as dementia, medication administration, in addition Staff #1(S1) who is a live in caregiver, was observed to not have valid CPR/ first aid certification or have completed their initial training. Deficiency cited. S1 was observed to be sleeping inside the closet in the master bedroom which belongs to Resident #1 (R1) and Resident #2 (R2). No citation was issued as S1 moved into the vacant bedroom during LPAs visit. LPA observed for there to be video surveillance inside R1 and R2s bedroom, there were no written consents
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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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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: ROSE GARDEN CAPO
FACILITY NUMBER: 374604380
VISIT DATE: 08/26/2024
NARRATIVE
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observed inside their files, LPA did not observe that R1 and R2 were also informed that their room would be monitored by video surveillance. Per administrator there is no audio only visual and he is the one that has control over the camera, that is done via cellphone. There was no deficiency issued as the camera was removed during LPAs visit.

The Administrator Rolando Corpuz was observed to have an administrator certificate that expired on 08/12/24. Per Rolando there are CEUs that still need to be completed and should be done in September 2024. Deficiency cited

On 8/01/24 LPA conducted a file review and observed for the facility annual fees to not have been paid, LPA followed up during today's visit and observed that the annual fees had not been paid, however the issue was resolved during LPAs visit.

Based on today's visit citations were issued on the attached 809D, in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of this report, appeal rights, LIC9098-Proof of Corrections form, were provided to Rolando Corpuz, Administrator.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/26/2024 12:21 PM - It Cannot Be Edited


Created By: Javina George On 08/26/2024 at 11:33 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: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above 2 out of 2 times, as there were no drills observed to have been completed for the 2024 year,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2024
Plan of Correction
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The licensee agrees to enroll S1 and S3 into CPR/First Aid training, and then have S1 complete the training. Proof is to be submitted to the department by 5pm on the due date indicated.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 times, as there were no drills observed to have been completed for the 2024 year,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2024
Plan of Correction
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The Licensee agrees to conduct a drill, document the necessary steps taken and submit proof to the department by 5pm on the due date indicated.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/26/2024 12:21 PM - It Cannot Be Edited


Created By: Javina George On 08/26/2024 at 11:45 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: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 times which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
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The Licensee agrees to have the Administrator certifcation completed. Proof of POC is to be submitted by 5pm on the due date indicated.
Type B
Section Cited
HSC
1569.625(b)(2)
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 3 times which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
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Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 3 times which poses a potential health, safety or personal rights risk to persons in care.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024


LIC809 (FAS) - (06/04)
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