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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003448
Report Date: 03/10/2022
Date Signed: 03/10/2022 10:59:28 AM


Document Has Been Signed on 03/10/2022 10:59 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:FULLERTON ROSEWOOD ASSISTED LIVINGFACILITY NUMBER:
306003448
ADMINISTRATOR:JANE KIMFACILITY TYPE:
740
ADDRESS:411 E. COMMONWEALTH AVENUETELEPHONE:
(714) 441-0644
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY:99CENSUS: DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facilty in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by caregiving staff after explaining the purpose of the visit. Staff called Licensee Joon Kim and Administrator Jane Kim who arrived later.

At approximately 9:45am, LPA accompanied by licensee Joon Kim began the tour of the facility. There are currently fifty six (56) residents in care. Some residents are observed relaxing in their bedrooms or in the common areas and appears well taken care of. Facility appears to be clean, sanitary and free of odors in all areas inspected. LPA observed a sample of occupied and unoccupied bedrooms, each of which is observed to have all required components. Bathrooms observed are equipped with grab bars and slip mats.
LPA observed a check-in station next to the entrance of the facility where temperature checks are being documented for visitors and staff. LPA observed the facility has COVID-19 Precautions posters, all required department postings and hand washing signs posted throughout. The facility has completed and submitted their LIC808 Mitigation Plan on 05/28/2021.
LPA observed a sufficient supply of food and water. A 15-day supply of medication is stored and locked. Facility has an adequate supply of PPE. LPA toured the outside of the facility. Clutter and two power tools are observed to be stored outside between the kitchen and a shed after having been used recently. Items were cleared during visit. There is a water fountain on the premises with no observed standing water.

Based on the observations made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report and appeals right were provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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 03/10/2022 10:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: FULLERTON ROSEWOOD ASSISTED LIVING
FACILITY NUMBER: 306003448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87303(a)
"The facility shall be clean, safe, sanitary and in good repair at all times."

This requirement is not met as evidenced by: LPA observed the presence of power tools stored in the facility's courtyard.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2022
Plan of Correction
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Facility staff removed dangerous equipment during the visit. LPA was able to confirm the removal before leaving the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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