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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005786
Report Date: 04/05/2022
Date Signed: 04/05/2022 02:43:59 PM


Document Has Been Signed on 04/05/2022 02:43 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:
04/05/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Shara Lajom and Tina ShalabyTIME COMPLETED:
03:00 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 03/17/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Tina Shalaby arrived during the visit.

During the visit, LPA toured the facility and observed the following:

*Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to Care of Persons with Dementia has been cleared. Licensee secured medications. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87405(a) pertaining to Administrator Qualifications has been cleared. Licensee provided proof of corrections. Licensee has complied with the terms of the POC.

During the visit, LPA observed the documentation of staff and resident temperatures as well as all the burners on the cook top are functional.




Licensee has been advised to maintain all items especially those that were previously deficient in the facility in accordance with Title 22 Regulations.

A copy of this report has been 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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