306005786-4-18-2024-22-AS-MTEA-D4FQVW-20240418123101

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005786
Report Date: 04/18/2024
Date Signed: 04/18/2024 12:31:35 PM

Document Has Been Signed on 04/18/2024 12:31 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:	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: 5	DATE:	04/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Tina Shalaby		TIME COMPLETED:	12:45 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) Michael Tea and Kimberly Lyman conducted an unannounced visit to Rosehaven III Care Home. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs was allowed entry into the home and met with Administrator Tina Shalaby. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 3 residents and the home currently has 5 residents. There are no residents on hospice during today's visit and one resident receiving home heatlh care service. LPAs Tea and Lyman along with Administrator Tina toured the facility at 8:45 AM. LPAs toured the physical plant, checked food service, and the first aid kit. Facility appears to be clean, safe, and sanitary. The home consists of four resident bedrooms, two and half resident bathrooms, one staff room, one shared hall bathroom, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPAs observed three residents with a half bed rails. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 108.6 and 110 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. During today's visit, auditory door alarms are operational. The entry door into the garage is secured. LPAs observed a locked storage area for cleaning supplies under the kitchen sink. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPAs observed sharps locked in a kitchen drawer. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPAs toured the outside grounds and there is ample shaded seating for residents. Exit gates are unlocked. LPAs observed ample emergency food and water supply. LPAs reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 03/05/2024. Facility provides activities in the form of exercise, physical therapy and bible studies. CONT ON LIC809-C DATED 04/18/2024.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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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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: ROSEHAVEN III CARE HOME	FACILITY NUMBER: 306005786
	VISIT DATE: 04/18/2024

NARRATIVE

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At 10:00 AM, LPAs reviewed five resident files and three staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Staff files reviewed contained required documentation of annual training, health screen/TB, and criminal record clearance. At 11:15 AM, LPAs reviewed medication storage and administration. Medications are stored in a locked cabinet and are audited monthly by staff. Medications are being administered per physician order.

Based on the observations made during today's visit, no deficiencies are being cited.
Exit interview conducted and a copy of this report was given at time of visit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

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