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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800187
Report Date: 10/07/2024
Date Signed: 10/07/2024 04:30:04 PM


Document Has Been Signed on 10/07/2024 04:30 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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: 5DATE:
10/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Mistie Felton, House ManagerTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Magda Malcore and Renese Howell-Small initiated a case management based on deficiencies observed during complaint investigation #56-AS-20241004092109 visit. LPA's met with House Manager, Mistie Felton and informed the purpose of the visit.

LPAs requested to review files for resident #1 (R1) who left the facility in August 2024 and resident #2 (R2) who left in July 2024. LPAs were informed by the House Manager that the facility not longer had record of both residents.

A deficiency is being cited in accordance of Title 22, division 6, of the California Code of Regulations. An exit interview was conducted where this report and a plan of correction was discussed. A copy of this report was provided with Appeal Rights to the House Manager at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024
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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Document Has Been Signed on 10/07/2024 04:30 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ROSE VALLEY REDLANDS
FACILITY NUMBER: 361800187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2024
Section Cited
CCR
87506(e)

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87506 Resident Records(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by:
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The Licensee/Administrator shall submit a self-certified statement of understanding on the regulation cited and submit the statement to the Licensing Agency by POC due date.
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The licensee did not comply with the section cited above by not maintaining records for resident #1 and resident #2 at the facility for 3 years after termination of services, which poses a potential health, safety or personal rights risk to persons in care.
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024
LIC809 (FAS) - (06/04)
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