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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003893
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:12:04 PM


Document Has Been Signed on 09/18/2024 04:12 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
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: 6DATE:
09/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Jay PichikaTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with a plan of correction visit (POC). LPA was greeted and granted entry into the facility and explained the reason for the visit.

Upon entry, LPA observed two staff present are not cleared or associated to facility. During the POC visit, LPA observed a broken kitchen cupboard, tile buckling on floor by front door, and a large pile of debris in the yard.

LPA consulted with Licensee regarding staffing. Licensee indicates two staff will be arriving in the evening to work. LPA verified that both staff are cleared and associated to the facility. Licensee to forward a copy of the LIC 500 by close of business 09/23/2024.

Licensee has been advised a meeting will be scheduled at the Orange County Regional office to discuss facility non-compliance.


Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
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 2


Document Has Been Signed on 09/18/2024 04:12 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
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: 09/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2024
Section Cited
CCR
87355(e)(1)

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All individuals subject to a criminal record review.. shall prior to working, residing or volunteering in a licensed facility:
Obtain a California clearance or a criminal record exemption.. This req is not being met as evidenced by:
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Licensee to obtain criminal record clearance and association for Staff 1 and 2 and forward proof to LPA by POC due date.
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Based on interview and record review, Licensee failed to ensure two staff obtained criminal record clearance. This poses an immediate health and safety risk to residents in care.
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Type B
10/02/2024
Section Cited
CCR87303(a)

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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 req is not being met as evidenced by:
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Licensee to repair/ remove noted items and forward proof to LPA by POC due date.
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Based on observation, Licensee failed to ensure facility is clean, safe and sanitary. LPA observed a broken cupboard, buckling tile, and debris in yard. 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: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2