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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003893
Report Date: 10/11/2024
Date Signed: 10/11/2024 03:36:44 PM


Document Has Been Signed on 10/11/2024 03:36 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: DATE:
10/11/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Jay PichikaTIME COMPLETED:
03:15 PM
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Licensing Program Manager (LPM) Alisa Ortiz, and Licensing Program Analyst (LPA) Kimberly Lyman, conducted an informal office meeting with Licensee Jaya Pichika to discuss general compliance concerns at the facility.

The following items were discussed during the meeting:
  • Staffing levels and schedule.
  • Physical plant issues.
  • Lack of communication between licensee and the department.
  • Non-compliance with citations.
  • Licensing fees
  • Reporting requirements

Licensee agrees as follows:
  • Licensee to communicate with the department on all issues or concerns regarding facility operations.
  • Licensee agrees to contact department for clarification and not make assumptions.
  • Licensee to forward a copy of the LIC 500 to LPA by 10/14/2024 that ensures coverage during hours when residents require services.
  • Facility will maintain compliance of Title 22 at all times and failure to maintain compliance may result in the department taking further action.

During the visit, Licensee was offered technical support services with the department and Licensee agreed to a referral for the service.

Exit interview conducted and a copy of this report was provided to Administrator.


SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2024
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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