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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800187
Report Date: 11/23/2022
Date Signed: 11/23/2022 02:58:44 PM


Document Has Been Signed on 11/23/2022 02:58 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
, CA 92507



FACILITY NAME:ROSE VALLEY REDLANDSFACILITY NUMBER:
361800187
ADMINISTRATOR:GLENN BERNALFACILITY TYPE:
740
ADDRESS:153 S DEARBORN STTELEPHONE:
(909) 389-7586
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY:6CENSUS: 6DATE:
11/23/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Iren CreightonTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Anna Bueno and Amber Coleman conducted an unannounced visit to subsequently investigate and deliver findings for complaint number: 18-AS-20201006151422. LPAs met with assistant administrator Iren Creighton who was explained the purpose of today’s visit.

During complaint investigation, records reviewed revealed that one of six residents have a Dementia diagnosis. This facility is not licensed to admit Dementia residents and this facility does not hold a dementia care plan. This poses an immediate health and safety risk to residents in care. Refer to LIC-809D for deficiency cited.

An exit interview was discussed with assistant administrator Iren Creighton. A copy of this report, LIC 809D, and appeal rights were provided to MS. Creighton.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022
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 2


Document Has Been Signed on 11/23/2022 02:58 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
, CA 92507


FACILITY NAME: ROSE VALLEY REDLANDS
FACILITY NUMBER: 361800187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/25/2022
Section Cited

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Plan of Operation - A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b).
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This requirement was not met as evidenced by:

Resident 1 has a primary diagnosis of Dementia.
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2