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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003893
Report Date: 03/21/2022
Date Signed: 03/21/2022 12:51:10 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20211025141423
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
UNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Amparo Mancillas and Jericho De CastroTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Administrator did not provide residents with privacy.
Administrator not demonstrating good character required of the position.
Administrator did not treat resident with dignity.
Facility is in disrepair.
Facility has pests.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kimberly Lyman and Edward Tapia made an unannounced visit to the facility today to deliver findings. LPAs met with Caregiver Amparo Mancillas and discussed the reason for visit. Administrator Jaya Pichika arrived during the visit.

During the course of the investigation, LPA toured the facility and interviewed staff and witnesses. Regarding the allegations that Administrator did not provide residents with privacy, Administrator not demonstrating good character required of the position, Administrator did not treat resident with dignity, facility is in disrepair and facility has pests, the investigation revealed the following: On October 19, 2021, Resident 1 (R1) was actively passing. Family members were present at the time. Three out of four witnesses interviewed state hearing a verbal altercation between Administrator and R1's family member in R1's room with family member requesting the administrator to leave the room. Witnesses state the altercation was heated and occurred while the resident was passing. Witnesses indicate Administrator is very vocal in disagreements with staff in front of families and residents. Administrator admits a video camera was put CONTINUED ON LIC 9099C DATED 03/21/2022.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 22-AS-20211025141423
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2022
Section Cited
CCR
87468.2(a)(2)
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In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents.. shall have all of the following personal rights:
To have a reasonable level of personal privacy in accommodations... and meetings of resident and family groups. This req not being met..
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Licensee removed the camera prior to complaint investigation.
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Based on interviews conducted, Licensee failed to ensure a reasonable level of privacy was provided to residents. Administrator admits to putting a video camera up in the living room without any consent from residents or responsible parties. This poses a potential health and safety risk to residents in care.
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Type B
04/04/2022
Section Cited
CCR
87405(d)
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The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not being met as evidenced by:
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Licensee to provide a written statement of understanding administrator qualifications and forward proof to LPA by POC due date.
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Based on observation and interviews conducted, Licensee did not have qualifications for operation of facility. Administrator does not have a current certificate and allowed personal rights violations, pests in the facility, and facility to be in disrepair. This poses a potential health, safety, or personal rights violation.
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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
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 22-AS-20211025141423
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2022
Section Cited
CCR
87468.1(a)(1)
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7
Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not being met as evidenced by:
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Licensee to submit a written, detailed plan on how to handle family discussions privately and with dignity and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure resident is accorded dignity. During R1's passing, Licensee was involved in a verbal altercation with R1's family member while family member was asking for privacy. This poses an immediate 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: 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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20211025141423
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/31/2022
NARRATIVE
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up in the living room without consent from responsible parties but states it was removed after reviewing licensing regulations. Witnesses confirm the video camera was in the living room. During tour of the facility, LPA observed items in disrepair in the facility including broken cupboards, an entrance ramp in disrepair, broken furniture on the patio, and kitchen cupboard missing molding. During the course of the investigation, LPA observed that Administrator has not had a current administrator certificate since 09/30/2019. LPA observed cockroaches in the kitchen cupboards and resident room. Based on observations made and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of .Regulations, (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D.

Citation previously issued on 11/02/2021 for the allegation of facility in disrepair
Citation issued previously on 11/23/2021 facility has pests.
Citation previously issued on 11/02/2021 for lack of current administrator certificate.

Exit interview conducted and a copy of the report provided as well as appeal rights..
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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20211025141423

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:
01/31/2022
UNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Amparo Mancillas and Jericho De CastroTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Administrator did not ensure adequate food supplies were in the home.
Facility is dirty.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kimberly Lyman and Edward Tapia made an unannounced visit to the facility today to conduct a 10-day visit and initiate an investigation on the above allegations. LPA Lyman met with Caregiver Amparo Mancillas and discussed the reason for visit. Administrator Jaya Pichika arrived during the visit.

During the course of the investigation, LPA toured the facility and interviewed staff and witnesses. Regarding the allegations that Administrator did not ensure adequate food supplies were in the home and facility is dirty, the investigation revealed the following: LPA observed the food supply on two different occasions. On both occasions the food supply was ample. LPA did not observe any food deficiencies during visit. During the tour of the facility, LPA observed cockroaches and rat droppings but facility was generally clean during visit. Due to conflicting information, LPA is unable to corroborate allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5