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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408373
Report Date: 02/09/2024
Date Signed: 02/09/2024 05:23:27 PM


Document Has Been Signed on 02/09/2024 05:23 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ROSEMONT VILLAFACILITY NUMBER:
336408373
ADMINISTRATOR:FE MAESTRADOFACILITY TYPE:
740
ADDRESS:6116 BIG HORN DRIVETELEPHONE:
(951) 787-4931
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY:6CENSUS: 6DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Fa Maestrado, AdministratorTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card.

Resident record review began. Six (6) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans/Individual Program Plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. One (1) medical assessment was not current. LPA interviewed three (3) residents.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 120.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals inside of room inside the home. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location.



Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized.
(Continued on next page)
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ROSEMONT VILLA
FACILITY NUMBER: 336408373
VISIT DATE: 02/09/2024
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(Continued from page 1)

LPA began review of employee records. Two (2) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and there is no current administrator certification observed. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and expired 07/28/2021.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguisher are tested or replaced annually and were last done so on 01/12/24. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 12/06/2023.

LPA allocated time to prepare this report for delivery.

Based on the information received during this visit today, there are three (3) deficiencies that is being cited per Title 22, Division 6 of The California Code of Regulations.

This report, 809 D and Appeal Rights was reviewed with and a copy provided to the facility representative.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/09/2024 05:23 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ROSEMONT VILLA
FACILITY NUMBER: 336408373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado observation, interview and record review, the licensee did not comply with the section cited above in an expired Administrator Certificate was observed, records review that Administrator has insufficient training hours to fulfill the completion of obtaining a certificate that is a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Administrator will submit required documents to obtain a valid current Administrator certificate and submit a copy of fullment of receiving the certificate via email 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
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in one (1) of six (6) resident did not have a current LIC 602 in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Licensee will obtain a current LIC 602 for resident and email a copy 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.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 02/09/2024 05:23 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ROSEMONT VILLA
FACILITY NUMBER: 336408373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in no emergency food was observed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Licensee will obtain and store at the facility emergency food for the capacity of all residents in care and staff for 72 hours. Licensee will email receipt of emergency food purchased and a photograph 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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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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4