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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408373
Report Date: 02/03/2025
Date Signed: 02/03/2025 04:31:13 PM

Document Has Been Signed on 02/03/2025 04:31 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ROSEMONT VILLAFACILITY NUMBER:
336408373
ADMINISTRATOR/
DIRECTOR:		FE MAESTRADOFACILITY TYPE:
740
ADDRESS:6116 BIG HORN DRIVETELEPHONE:
(951) 787-4931
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
02/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Fe Maestrado, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 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. Five (5) 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. LPA interviewed two (2) 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 118.0 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. LPA observed a bottle of Lysol bleach toilet bowl cleaner under resident's bathroom sink, unsecured. Two exterior window screens need replacing and sliding door screen is missing.



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.

LPA began review of employee records. Three (3) records were reviewed. LPA reviewed employee record for (Continued on next page)
Jazmond D HarrisTELEPHONE: (951) 248-0318
Yolanda DelgadoTELEPHONE: (951) 203-2990
DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ROSEMONT VILLA
FACILITY NUMBER: 336408373
VISIT DATE: 02/03/2025
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for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and there current administrator certification

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 07/29/2025.

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 01/7/25. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 12/28/2024. There are no firearms stored and no bodies of water observed.

LPA allocated time to prepare this report for delivery.

Based on the information received during this visit today, there are two (2) deficiencies with Civil Penalties issued for $500 that is being cited per Title 22, Division 6 of The California Code of Regulations.

This report, 809 D, LIC421IM 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: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/03/2025 04:31 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: 02/03/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 a Lysol Bleach toiletbowl bottle was under Residen't bathroom sink in an unlocked cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2025
Plan of Correction
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Licensee immediately had staff remove bottle and will re-train staff on the proper storage of cleaning solutions and submit training sheet 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.
Jazmond D HarrisTELEPHONE: (951) 248-0318
Yolanda DelgadoTELEPHONE: (951) 203-2990

DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/03/2025 04:31 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: 02/03/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

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 2 exterior windo screens need replacing and 1 sliding door had no screen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2025
Plan of Correction
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Licensee will obtain and install screens for windows and door and email the invoice 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.
Jazmond D HarrisTELEPHONE: (951) 248-0318
Yolanda DelgadoTELEPHONE: (951) 203-2990

DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025

LIC809 (FAS) - (06/04)
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