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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003893
Report Date: 04/05/2022
Date Signed: 04/05/2022 01:45:27 PM


Document Has Been Signed on 04/05/2022 01:45 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: 4DATE:
04/05/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Red SantosTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 03/21/2022. LPA was greeted and granted entry into the facility by Caregiver Red Santos and explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 87303(a) pertaining to Maintenance and Operation has been cleared. Licensee cleared noted items. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87468.2(a)(2) pertaining to Personal Rights has been cleared. Licensee removed camera in living room. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87405(a) pertaining to Administrator Qualifications has NOT been cleared. Licensee did not provide proof of correction. Licensee has NOT complied with the terms of the POC. CIVIL PENALTY ISSUED.

*Deficiency cited under Title 22 Regulation 87468.2(a)(1) pertaining to Personal Rights has NOT been cleared. Licensee did not provide proof of correction. Licensee has NOT complied with the terms of the POC. CIVIL PENALTY ISSUED.


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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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