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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003893
Report Date: 07/19/2024
Date Signed: 07/19/2024 03:54:54 PM


Document Has Been Signed on 07/19/2024 03:54 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
Lookup Error,
, CA



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: 6DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Jayalakshmi PichikaTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The
facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the
purpose of the visit with Caregiver Jesus Lopez. Administrator Jay Pichika arrive shortly after. According to the facility’s license, the facility has a maximum capacity of six residents, of whom all may be non-ambulatory, one of which may be bedridden.

LPA toured the interior and exterior of the facility and inspected each room. There were multiple issues with the physical plant- room 6 walkway was semi-obstructed with construction tools, a large mirror and construction debris. Additionally there was a toilet in front of the closet which contained dark brown water. Double vanity outside room six is not in working condition, per residents has not worked in weeks.
Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Sink in double vanity was not draining water. Shower floors had dark mold and non-slip pads were slimy.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications labeled and locked as required.

No pool or body of water was present. Water temperature was measured at 113 degrees F. Per Jay, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit was complete.

Resident records reviewed did not contain Needs and Services Plans. Staff records reviewed did not have current first aid training in two of two records.
Additionally, LPA informed Administrator of annual fees due to the Department.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2333
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 07/19/2024 03:54 PM - 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
Lookup Error,
, CA


FACILITY NAME: ROSEHAVEN 1
FACILITY NUMBER: 306003893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not comply with the section cited above in 6 of 6 residents which poses safety risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee cleared up obstructed area during today's visit and will conduct a through cleaning of mold by POC date.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the licensee did not comply with the section cited above in six of six resident which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Licensee agrees to finish construction on double vanity not currently operational and work on non-draining sink by POC date. Licensee request 30 day for construction to be completed.
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: Simon JacobTELEPHONE: (619) 767-2333
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 07/19/2024 03:54 PM - 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
Lookup Error,
, CA


FACILITY NAME: ROSEHAVEN 1
FACILITY NUMBER: 306003893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(a)(1)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed the licensee did not comply with the section cited above in two of two staff which poses health, risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee agrees to provide training to staff by POC date and provide LPA proof.
Reappraisals

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: Simon JacobTELEPHONE: (619) 767-2333
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: ROSEHAVEN 1
FACILITY NUMBER: 306003893
VISIT DATE: 07/19/2024
NARRATIVE
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Multiple deficiencies were provided on todays date and one technical violation. An exit interview was conducted with Administrator, to whom a copy of this report,(LIC9099-x3), LIC9102, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2333
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 07/19/2024 03:54 PM - 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
Lookup Error,
, CA


FACILITY NAME: ROSEHAVEN 1
FACILITY NUMBER: 306003893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(1)
(a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility.
(1) At a minimum the written record shall include the date of the meeting, name of individuals who participated and their relationship to the resident, and the agreed-upon services to be provided to the resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed the licensee did not comply with the section cited above in six of six residents which poses personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee agrees to create and discuss needs and services plans with residents and provide proof to LPA by POC date
Type B
Section Cited
CCR
87411(c)(1)
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on records reviews the licensee did not comply with the section cited above in two of two staff which poses a potential safety risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee agrees to provide LPA with proof of first aid training by POC date.
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: Simon JacobTELEPHONE: (619) 767-2333
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5