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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003893
Report Date: 09/28/2022
Date Signed: 09/28/2022 10:57:21 AM


Document Has Been Signed on 09/28/2022 10:57 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: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: 4DATE:
09/28/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Antonio GaspiTIME COMPLETED:
11:12 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced health and safety case management visit. LPA was greeted and granted entry into the facility by Caregiver Antonio Gaspi and explained the reason for the visit.

During the visit, LPA toured the facility and spoke with residents. LPA observed fans in all resident rooms as well as common areas. LPA spoke with three out of four residents who confirmed the facility was appropriately cooled. Residents verbalized satisfaction with the facility and appeared happy and well taken care of. Facility temperature during today's visit was 73 degrees F.









Based on the observations made during today's visit, no deficiencies are being cited. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
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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