306005786-3-12-2021-22-AS-KLYN-BZ2NX4-20210312095031

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005786
Report Date: 03/12/2021
Date Signed: 03/12/2021 09:50:36 AM

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 III CARE HOME		FACILITY NUMBER:	306005786
ADMINISTRATOR:	SHALABY, TINA LE		FACILITY TYPE:	740
ADDRESS:	309 CALLE SANDIA		TELEPHONE:	(949) 836-4817
CITY:	SAN CLEMENTE	STATE: CA	ZIP CODE:	92672
CAPACITY:	6	CENSUS: 2	DATE:	03/12/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Tina Shalaby		TIME COMPLETED:	09:50 AM

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 Analyst (LPA) Kimberly Lyman contacted the facility via telephone to conduct a pre-licensing visit via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call with Administrator Tina Shalaby. An initial application to operate a Residential Facility for the Elderly was received by CCL on 03/04/2020 for a capacity of 6 non-ambulatory residents. There are 2 residents in care during today's visit. Administrator Shalaby has an administrator certificate expiring on 05/21/2021. Covid vaccines have been administered with a 100 percent cooperation from staff and residents. LPA Lyman along with Administrator Tina Shalaby toured the facility via FaceTime at 8:10 AM and observed the following: Structure: Facility is a one story, 4 bedroom, 3 bathroom house with an attached garage and a white and gray exterior. The exit gates are closed and unlocked. Living Room/ Dining Room: Adequate seating is available in the dining room, living room, and family room. Bedrooms Residents: Two resident bedrooms are single occupancy. All rooms are equipped with appropriate lighting, chair, night stand, ample closet space and televisions for resident viewing. All exit doors are equipped with working auditory exit alarms. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Linen supply is in ample supply for residents in care. Emergency Phone Numbers and Exit Plan: Available for review in the entrance area of the facility. Food Service: Facility has ample 2 day perishables as well as 7 day non-perishables in the pantry. Facility uses a menu. Smoke Detectors: Smoke detectors are centrally wired and were tested operational. Fire extinguishers are mounted and charged. Carbon monoxide detector tested operational during today's visit. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins: Locked/stored in a cupboard in kitchen as well as a closet in the hallway. Water Temperature: Tested and recorded at 109 degrees F. in facility bathrooms. Emergency Supplies: LPA observed ample emergency food and water as well as emergency backpacks for all residents in care. CONT ON LIC 809C DATED 03/12/2021.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

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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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 III CARE HOME	FACILITY NUMBER: 306005786
	VISIT DATE: 03/12/2021

NARRATIVE

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Medications, First-Aid Kit & Book: First aid kit observed contained all required items. LPA observed completed emergency disaster plan. Medication is stored and locked in a locked closet in the entry of the facility. Facility uses a medication administration record. Resident & Staff File: Records are locked in a closet in the hallway. Reading Material, Games, and Equipment: LPA observed a copy of the activity schedule including exercise and music therapy. Backyard: LPA observed a clean, safe backyard with ample shaded seating for residents. LPA observed seating for outdoor covid visitation. Fire Clearance: Approved for 6 non-ambulatory residents on 12/07/2020.

The facility is ready to be licensed. As noted above, a Component III was conducted during this visit as well.

An exit interview was conducted with Administrator Shalaby via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

LIC809 (FAS) - (06/04)

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