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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004441
Report Date: 10/02/2024
Date Signed: 10/02/2024 11:44:36 AM

Document Has Been Signed on 10/02/2024 11:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ROSIE'S RESIDENTIAL CAREFACILITY NUMBER:
306004441
ADMINISTRATOR/
DIRECTOR:		JAIME RUALOFACILITY TYPE:
735
ADDRESS:1921 W.HALL AVENUETELEPHONE:
(714) 831-1335
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY: 6CENSUS: 4DATE:
10/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Karry Vallejo-Administrator, Maricela Marin-Administrator AssistantTIME VISIT/
INSPECTION COMPLETED:
11:59 AM
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Administrator (AD) Karry Vallejo.

For today’s visit, LPA observed a total of one client in care and one staff member on duty.

LPA observed the Administrator's Certificate for facility AD Karry Vallejo which expires on January 01, 2025

LPA Ramirez toured the interior and exterior portions of the facility with AD Vallejo. The facility is a one-story home and is licensed for six ambulatory clients. There are a total of five bedrooms of which four are for client bedrooms and one for staff. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. LPA observed all windows were screened. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of two restrooms. Restrooms were observed to be in good repair and toilets were operational. Water temperature tested between 109.7-114.0 degrees Fahrenheit.

Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Fire extinguisher was observed to be fully charged and mounted by the dining room. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable.

CONTINUED ON LIC809-C..

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ROSIE'S RESIDENTIAL CARE
FACILITY NUMBER: 306004441
VISIT DATE: 10/02/2024
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LPA Ramirez observed the emergency disaster and evacuation plan, which is located by living room. Facility had back-up emergency food and water supply. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to clients in care.

For the exterior portion, LPA Ramirez observed a shaded area, patio furniture, and the grounds were free of any hazards. There is one gate in the backyard which is self-closing and self-latching. No bodies of water were observed.

LPA reviewed four of four client files and three staff files. LPA also reviewed client money and ledger for four of four clients. LPA interviewed one client and two staff.

During today's visit LPA observed client relaxing in their bedroom and playing a puzzle with staff.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Vallejo.

A copy of this report was provided at the time of exit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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