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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003893
Report Date: 03/21/2022
Date Signed: 03/21/2022 12:53:09 PM


Document Has Been Signed on 03/21/2022 12:53 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: 5DATE:
03/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Amparo Mancillas and Jaya PichikaTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Edward Tapia conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20211025141423. LPAs were greeted and granted entry into the facility by Caregiver Amparo Mancillas and explained the reason for the visit. Administrator/ Licensee Jay Pichika arrived during the visit.

During the course of the complaint visit, LPAs observed the following:
There are various discarded items such as bed frame, mattress, pulley, broken drawers and AC unit in driveway area.






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: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
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 03/21/2022 12:53 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: 03/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2022
Section Cited

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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 requirement is not being met as evidenced by:
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Based on observation, Licensee failed to ensure facility is clean, safe, and sanitary. LPAs observed discarded items in the front of the driveway. This poses a potential health and safety risk to residents in care. CIVIL PENALTY ASSESSED.
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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: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
LIC809 (FAS) - (06/04)
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