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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411948
Report Date: 12/20/2023
Date Signed: 12/20/2023 10:29:59 AM


Document Has Been Signed on 12/20/2023 10:29 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:ROSE ALLEY GUEST HOME IIFACILITY NUMBER:
366411948
ADMINISTRATOR:RADOI, ANAFACILITY TYPE:
740
ADDRESS:35655 TERIANN LANETELEPHONE:
(909) 797-5512
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY:6CENSUS: 2DATE:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Ana Radoi-Administrator TIME COMPLETED:
10:45 AM
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Licensing Program Analysts (LPA's) Bernadette Allen made an unannounced visit to the facility to conduct an annual inspection. At the time of the visit there was two (2) staff members and two(2) residents. LPA met with Ana Radoi- Administrator who was informed of the purpose of the visit.

LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

The Indoor and outdoor passageways were kept free of obstruction. The facility has sufficient furniture and lighting and is maintained at a comfortable temperature.

There was enough nonperishable and perishable food for the number of residents in care. The facility has a variety of food available for residents, and a menu was available for review. The facility food is stored in a safe manner. Sharps are stored and locked in a drawer inaccessible to clients in care.

The resident’s bedrooms are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting.

The bathrooms had non-slip mats and were operating in a safe and in good sanitary condition. The hot water temperature measured between 105-120-degrees F. LPA also observed the facility is equipped with operating carbon monoxide/smoke detectors and fully charged fire extinguishers.

Posters such as personal rights and the disaster plan were posted in a common area.

LPA did observe cleaning supplies, toxins items are kept in a locked in laundry room. inaccessible to clients in care.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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
, CA 92507
FACILITY NAME: ROSE ALLEY GUEST HOME II
FACILITY NUMBER: 366411948
VISIT DATE: 12/20/2023
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LPA reviewed two(2) client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

An exit interview was conducted, and this report was discussed and provided to Ana Radoi- Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC809 (FAS) - (06/04)
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