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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003893
Report Date: 07/29/2022
Date Signed: 07/29/2022 09:55:54 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/05/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220705085643
FACILITY NAME:ROSEHAVEN 1FACILITY NUMBER:
306003893
ADMINISTRATOR:JAYALAKSHMI PICHIKAFACILITY TYPE:
740
ADDRESS:203 CALLE DEL JUEGOTELEPHONE:
(949) 366-2599
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY:6CENSUS: 5DATE:
07/29/2022
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jaya PichikaTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Staff do not follow physicians orders to transfer resident every 2 hours
Staff did not provide resident's authorized representative with a copy of the Admission Agreement within the required time frame
Staff are not adequately trained to meet resident needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility today to deliver findings on the above allegations. LPA Lyman met with Caregiver Brenda Castillo and discussed the reason for visit. Administrator Jaya Pichika arrived during the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as admission agreement and staff training. Regarding the allegations that staff do not follow physicians orders to transfer resident every 2 hours, staff did not provide resident's authorized representative with a copy of the Admission Agreement within the required time frame and Staff are not adequately trained to meet resident needs, the investigation revealed the following: Resident 1 (R1) has a physician order dated 07/01/2022 indicating R1 is to be turned every two hours by facility staff. Two out of two staff state the resident is being turned every two hours. However, facility checklist for two hour turns indicate between July 1-12, 2022, it was not documented 24 times that the resident was turned. Additionally, witness indicates resident is not be turned regularly at night. Staff indicate their shift ends at 6 PM but work as needed to CONTINUED ON 9099C DATED 07/29/2022
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 22-AS-20220705085643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ROSEHAVEN 1
FACILITY NUMBER: 306003893
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2022
Section Cited
CCR
87464(f)(1)
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7
Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
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Licensee to submit a detailed, written plan on ensuring resident is being turned every two hours per physician order and forward proof to LPA by POC due date.
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Based on record review, Licensee failed to ensure care and supervision is being provided to R1. R1 has a physician order to turn resident every 2 hours. Facility documentation indicates R1 was not turned 24 times between July 1-12, 2022. This poses an immediate health and safety risk to residents in care. Civil Penalty Assessed.
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Type B
07/30/2022
Section Cited
CCR
87507(e)
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The licensee shall provide a copy of the signed and dated current admission agreement.., to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification...This requirement is not being met as evidenced by:
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Licensee to provide a copy of the signed admission agreement to R1/ Responsible Party and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure an admission agreement was provided to R1/ Responsible Party. This poses a potential health and safety 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20220705085643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ROSEHAVEN 1
FACILITY NUMBER: 306003893
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited
CCR
87412(c)
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7
Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not being met as evidenced by:
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Licensee to ensure all staff training is up to date and verification is maintained in staff file. Licensee to forward proof to LPA by POC due date.
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Based on record review, Licensee failed to ensure verification of staff training is maintained. Two out of four staff do not have documentation of required training. This poses a potential health and safety risk to residents in are.
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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) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20220705085643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ROSEHAVEN 1
FACILITY NUMBER: 306003893
VISIT DATE: 07/29/2022
NARRATIVE
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turn resident throughout the night. R1 admitted into the facility on 04/22/2022. Responsible Party states not receiving a copy of the admission agreement and Licensee/ Administrator admits to not providing a copy of the admission agreement. During the investigation, LPA reviewed staff training records. Two out of four facility staff do not have documented required training. Based on observations made and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of .Regulations, (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/05/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220705085643

FACILITY NAME:ROSEHAVEN 1FACILITY NUMBER:
306003893
ADMINISTRATOR:JAYALAKSHMI PICHIKAFACILITY TYPE:
740
ADDRESS:203 CALLE DEL JUEGOTELEPHONE:
(949) 366-2599
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY:6CENSUS: DATE:
07/29/2022
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:TIME COMPLETED:
09:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not meeting resident's toileting needs at night
INVESTIGATION FINDINGS:
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2
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5
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8
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10
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12
13
Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility today to deliver findings on the above allegations. LPA Lyman met with Caregiver Antonio Gaspi and discussed the reason for visit. Administrator Jaya Pichika arrived during the visit.
During the course of the investigation, LPA toured the facility and interviewed staff and residents. Regarding the allegation that staff are not meeting resident's toileting needs at night, the investigation revealed the following: The typical staff schedule at the facility is from 7AM-6PM however, staff indicate being available for assistance as needed and the residents have call buttons. Two out of two staff and Administrator interviewed indicated that R1 is being toileted at night. Administrator states they do not use double diapers or pads and are utilizing diapers with material that does not allow moisture to be on the resident. LPA interviewed two residents who were able to talk to LPA. Both residents stated no issues at night with toileting. The three other residents were unable to be interviewed due to cognition issues. Due to conflicting information, LPA is unable to corroborate allegations. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegations CONTINUED ON LIC 9099C DATED 07/29/2022.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20220705085643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ROSEHAVEN 1
FACILITY NUMBER: 306003893
VISIT DATE: 07/29/2022
NARRATIVE
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 may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6