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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005786
Report Date: 03/17/2022
Date Signed: 03/17/2022 02:45:40 PM


Document Has Been Signed on 03/17/2022 02:45 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 III CARE HOMEFACILITY NUMBER:
306005786
ADMINISTRATOR:SHALABY, TINA LEFACILITY TYPE:
740
ADDRESS:309 CALLE SANDIATELEPHONE:
(949) 836-4817
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY:6CENSUS: 3DATE:
03/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Liezel Turla and Tina ShalabyTIME COMPLETED:
10:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Tina Shalaby arrived during the visit. Administrator Shalaby has an administrator certificate that expired on 05/21/2021.

At 9:00 AM, LPA toured the facility with Administrator Shalaby. Facility has 3 residents in care during today's visit with 1 resident on hospice care. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements. Resident rooms are single and double occupancy. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a hand written visitor sign in sheet. Facility takes resident temperatures daily and documents. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. LPA observed an ample supply of emergency food and water. At 9:20 AM, LPA observed unsecured cleaning items in an unlocked cabinet. LPA observed the shaded outside visitation area. Exit gates are self latching and unlocked. LPA observed the locked medication area. Facility utilizes a medication administration record. Facility provides activities in the form of exercise and music therapy. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed all resident files during the visit and all files have updated emergency information as well as required documents. All residents and staff are vaccinated for Covid-19.
LPA consulted with administrator on the importance of screening all visitors and ensuring all staff are wearing masks.
Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
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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Document Has Been Signed on 03/17/2022 02:45 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ROSEHAVEN III CARE HOME
FACILITY NUMBER: 306005786

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
The following shall be stored inaccessible to residents with dementia:
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed unsecured cleaning items in an unlocked cabinet. This poses an immediate health and safety risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
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Licensee to secure items and forward proof to LPA by POC due date. Licensee secured items during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/17/2022 02:45 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ROSEHAVEN III CARE HOME
FACILITY NUMBER: 306005786

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
All facilities shall have a qualified and currently certified administrator.....

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed administrator certificate expired 05/21/2021. This poses a potential safety risk to persons in care.
POC Due Date: 03/31/2022
Plan of Correction
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Licensee to forward proof of completion/ submittal of certification requirements to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3