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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425370
Report Date: 03/26/2024
Date Signed: 03/26/2024 02:54:26 PM


Document Has Been Signed on 03/26/2024 02:54 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 ASC, 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: 6DATE:
03/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:28 PM
MET WITH:Karina Chaveres - Facility StaffTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Anna Fannell conducted an unannounced visit to this facility to deliver findings for complaint control number: 56-AS-20230103155228. LPA met with care provider Karina Chaveres who was informed of the reason for today's visit. Chavares notified Licensee Mazoor Massey of LPA's presence at the facility and Massey arrived shortly.

The report was discussed with and copy was provided to Licensee at the conclusion of today’s visit.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna FannellTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
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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