306005622-10-18-2024-22-AS-SHAN-DA6VR3-20241018163915

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005622
Report Date: 10/18/2024
Date Signed: 10/18/2024 04:39:54 PM

Document Has Been Signed on 10/18/2024 04:39 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ROSELLE CARE LLC		FACILITY NUMBER:	306005622
ADMINISTRATOR:	ROMEL BISDA		FACILITY TYPE:	740
ADDRESS:	226 HANNAH WAY		TELEPHONE:	(626) 617-8483
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS: 5	DATE:	10/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Remer Callado		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Samer Haddadin and Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs was greeted by Staff Romer Callado and granted entry into the facility. Administrator (AD) Romel Bisda arrived at approximately 10:45 a.m. and the purpose of the inspection was discussed. During the inspection LPAs and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following: This is a single-story house with five bedrooms, and two bathrooms, with one bedroom being occupied by staff. During the inspection LPAs observed three staff on duty and five residents in care. Residents were observed resting in their respective rooms and in the living room area. LPAs observed smoke detectors/carbon monoxide in common areas and bedrooms; all were operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPAs observed fire extinguisher mounted in kitchen area with last inspection date of on May 27^th,2021. Upon review, fire drill log indicated that the last drill was conducted on March 21st, 2024. During inspection of the kitchen area, LPAs observed sharps, knives, and a pair of scissors in kitchen drawer to be unlocked and accessible to residents in care. 2-day supply of perishable and 7-day supply of non-perishable foods and water was not observed during today’s visit. Kitchen appliances were observed to be operational during today's visit Restrooms toilets and water faucets were also observed to be operational. Grab bars were secure, and showers were observed to be free of mold/mildew. Underneath the bathroom sink, LPAs observed a bottle of powder bleach (Comet) and a bottle of window cleaner (Windex) to be unlocked and accessible to residents. Water temperature measured between at 111.2 degrees Fahrenheit and 111.7 degrees Fahrenheit. LPAs and AD toured the backyard of the facility and observed there is no shaded seating area. LPAs also observed and took a picture of a discarded mattress, in the backyard, which had discoloration and dead insects attached to the mattress (CONTINUE LIC 809C).

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Samer Haddadin	TELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

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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Document Has Been Signed on 10/18/2024 04:39 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROSELLE CARE LLC	FACILITY NUMBER: 306005622
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

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 met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as fire extinguisher was not serviced in the past 3 yrs . Multiple food items were observed to be expired in the refrigerator and a matress with dead insects observed in backyard, which poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 10/19/2024
	Plan of Correction
1 2 3 4	Staff immediately removed expired items from fridge. AD stated they will service fire extinguisher and discard of matress immediatly and will provide LPA proof via email by POC date.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as clearning solutions were observed to be accessible to residents, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/19/2024
	Plan of Correction
1 2 3 4	Staff immediately removed and locked items in the garage. AD stated they will conduct an in-service regarding proper storage of cleaning solutions and provide LPA proof via email by POC date.

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 Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Samer Haddadin	TELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/18/2024 04:39 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROSELLE CARE LLC	FACILITY NUMBER: 306005622
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and staff interview], the licensee did not comply with the section cited above as medication closet was observed to be unlocked and accessible, which poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 10/19/2024
	Plan of Correction
1 2 3 4	Staff immediately locked medication closet and AD stated they will provide staff training regarding proper medication storage and provide LPA a copy via email by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Samer Haddadin	TELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/18/2024 04:39 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROSELLE CARE LLC	FACILITY NUMBER: 306005622
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (record review, the licensee did not comply with the section cited above in three of three staff files, which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 11/18/2024
	Plan of Correction
1 2 3 4	AD stated staff training will be conducted and proof provided to LPA via email by POC date.

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on AD interview and record review, the licensee did not comply with the section cited above in three of three resident files which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 11/18/2024
	Plan of Correction
1 2 3 4	AD stated reappraisals will be completed and a copy provided to LPA via email by POC date.

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 Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Samer Haddadin	TELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/18/2024 04:39 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROSELLE CARE LLC	FACILITY NUMBER: 306005622
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, AD interview, and record review, the licensee did not comply with the section cited above as disaster drills are not being conducted at least quarterly, which poses a potential safety risk to persons in care.
	POC Due Date: 11/18/2024
	Plan of Correction
1 2 3 4	AD stated emergency disaster drills will be conducted quarterly and proof provided to LPA via email by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Samer Haddadin	TELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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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: ROSELLE CARE LLC	FACILITY NUMBER: 306005622
	VISIT DATE: 10/18/2024

NARRATIVE

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LPAs reviewed three residents’ files and observed three of three files do not have a current Needs and Services Plan. LPAs reviewed three staff files and observed three out of three staff files did not contain the 20-hour annual training.
Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights were provided to AD at end of inspection.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Samer Haddadin	TELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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