306005786-3-11-2025-22-AS-KLYN-DENP3C-20250311105720

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005786
Report Date: 03/11/2025
Date Signed: 03/11/2025 10:58:46 AM

Document Has Been Signed on 03/11/2025 10:58 AM - 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 HOME		FACILITY NUMBER:	306005786
ADMINISTRATOR/ DIRECTOR:	SHALABY, TINA LE		FACILITY TYPE:	740
ADDRESS:	309 CALLE SANDIA		TELEPHONE:	(949) 836-4817
CITY:	SAN CLEMENTE	STATE: CA	ZIP CODE:	92672
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	03/11/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:25 AM
MET WITH:	Tina Shalaby		TIME VISIT/ INSPECTION COMPLETED:	11:20 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 conducted an unannounced visit to Rosehaven III Care Home. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 3 residents and the home currently has 4 residents. There are no residents on hospice during today's visit and one resident receiving home health care service. Administrator Tina Shalaby has a current administrator certificate expiring on 05/21/2025. LPA Lyman along with Caregiver Annie Macaraeg toured the facility at 7:56 AM. Administrator Tina Shalaby arrived during the visit. LPA toured the physical plant, checked food service, reviewed records and the first aid kit. Facility appears to be clean, safe, and sanitary. The home consists of four resident bedrooms, two resident restrooms, common restroom, one staff room, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA 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 110.6 and 116.2 degrees F in all facility restrooms. 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. The entry door into the garage is secured. LPA 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. LPA 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. LPA toured the outside grounds and there is ample shaded seating for residents. Exit gates are unlocked. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 09/15/2024. Facility provides activities in the form of exercise and music therapy. CONT ON LIC809-C DATED 03/11/2025

Alisa Ortiz	TELEPHONE: (714) 703-2855
Kimberly Lyman	TELEPHONE: (714) 795-1497
	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

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: 03/11/2025

NARRATIVE

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At 9:00 AM, LPA reviewed four resident files and three staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Resident 4 (R4) does not have a medical assessment in the file. Staff files did not contain proof of training. Two out of three staff do not have association to the facility. At 9:30 AM, LPA 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, 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 Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2025 10:58 AM - 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: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 two out of three staff are not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care. CIVIL PENALTY ASSESSED.
	POC Due Date: 03/12/2025
	Plan of Correction
1 2 3 4	Licensee to associate noted staff and forward proof to LPA by POC due 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.

Alisa Ortiz	TELEPHONE: (714) 703-2855
Kimberly Lyman	TELEPHONE: (714) 795-1497
	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2025 10:58 AM - 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: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87412(c)

Personnel Records

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. 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 out of three staff without proof of training in the file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2025
	Plan of Correction
1 2 3 4	Licensee to conduct training and forward proof to LPA by POC due date.

Type B

Section Cited

CCR

87456(a)(3)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. 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 one out of four residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2025
	Plan of Correction
1 2 3 4	Licensee to obtain medical assessment and forward proof to LPA by POC due 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.

Alisa Ortiz	TELEPHONE: (714) 703-2855
Kimberly Lyman	TELEPHONE: (714) 795-1497
	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2025 10:58 AM - 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: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 record review, the licensee did not comply with the section cited above. The last emergency drill conducted was on 09/15/ 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2025
	Plan of Correction
1 2 3 4	Licensee to conduct emergency drill and forward proof to LPA by POC due 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.

Alisa Ortiz	TELEPHONE: (714) 703-2855
Kimberly Lyman	TELEPHONE: (714) 795-1497
	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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