<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425370
Report Date: 01/27/2022
Date Signed: 01/27/2022 03:51:56 PM

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:ROSE VILLAFACILITY NUMBER:
366425370
ADMINISTRATOR:MANZOOR R. MASSEYFACILITY TYPE:
740
ADDRESS:11906 KINGSTON STREETTELEPHONE:
(909) 825-7673
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:6CENSUS: 4DATE:
01/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Manzoor MasseyTIME COMPLETED:
03:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility to conduct a health and safety check following the receipt of complaint number: 18-AS-20220126143226. LPA met with staff Irene Changolla and informed them of the purpose of this visit. LPA phoned the licensee, Manzoor Massey, who arrived at the facility shortly.

The LPA conducted staff and resident interviews. Additional investigation will be conducted and citation issued if required. No immediate health and safety concerns were reported.

This report was reviewed with Mr. Massey and a copy was provided.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
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 1