366425370-8-22-2023-56-AS-MMAE-CUXTNA-20230822145226

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366425370
Report Date: 08/22/2023
Date Signed: 08/22/2023 02:52:44 PM

Document Has Been Signed on 08/22/2023 02:52 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 VILLA		FACILITY NUMBER:	366425370
ADMINISTRATOR:	MANZOOR R. MASSEY		FACILITY TYPE:	740
ADDRESS:	11906 KINGSTON STREET		TELEPHONE:	(909) 825-7673
CITY:	GRAND TERRACE	STATE: CA	ZIP CODE:	92313
CAPACITY:	6	CENSUS: 5	DATE:	08/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Manzoor Massey, Administrator		TIME COMPLETED:	03:05 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) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Manzoor Massey, Administrator and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) clients with a current census of (5). Hospice waiver for (2). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Fireplace is adequately screened. LPA observed outdoor pool is empty and enclosed with a locked fence inaccessible to clients in care. Backyard is also secured with latched gates. LPA inspected the kitchen. The refrigerator and freezer are operating in a safe and healthful manner. Hot water temperature is maintained at 106 degrees F. Facility has sufficient non-perishable and perishable food supply for the number of clients in care. Facility has sufficient cups, plates, and utensils for client use. Facility food is stored in a safe and healthful manner. LPA inspected client bedrooms. Bedrooms are equipped with beds, linen, nightstands, chairs, and sufficient lighting. LPA inspected client bathrooms. Bathrooms are operating in a safe and sanitary condition. The hot water temperatures in bathrooms tested between 106 and 108 degrees F.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ROSE VILLA	FACILITY NUMBER: 366425370
	VISIT DATE: 08/22/2023

NARRATIVE

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LPA observed the facility is equipped with operating carbon monoxide alarms. Facility has operating telephone service on the premises. Posters such as personal rights, Ombudsman contact, emergency phone numbers are posted in a common area. Sharps, disinfectants, cleaning solutions, and toxins are kept locked and inaccessible to clients in care. Administrator was not able to provide documentation of last fire/emergency drill. Deficiency cited.

Client medications are kept in a safe and locked cabinet inaccessible to clients in care. All medication are labeled and administered as prescribed.

LPA reviewed (3) staff files reviewed for first aid certifications, fingerprint clearances/exemptions, health screening, and training. All (3) staff files did not have record of required care facility training and/or hours of training. (1) staff did not have the proper background clearance. Deficiency cited.

LPA reviewed (3) client records reviewed had admissions agreements, physician's reports, assessments, and personal rights.

Deficiencies are being cited and civil penalties accessed during today's visit.

An exit interview was conducted, where reports (LIC809/LIC809D/LIC9102) were discussed and a copy of reports with appeal rights was provided to the Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/22/2023 02:52 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 VILLA	FACILITY NUMBER: 366425370
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA file review, the licensee did not comply with the section cited above with (1) staff not having proper background clearance prior to employment which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/23/2023
	Plan of Correction
1 2 3 4	Administrator to read the cited regulation and write a statement of understanding that uncleared staff shall not work at the facility until staff has received california clearance and/or exemption. Administrator shall submit this statement to the licensing agency by POC date

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/22/2023 02:52 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 VILLA	FACILITY NUMBER: 366425370
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(1)

Other Provisions

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA staff file review, the licensee did not comply with the section cited above by (3) staff not having record of required care training and/or hours which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2023
	Plan of Correction
1 2 3 4	Adminstrator has a file documenting training at the offsite office and will submit proof of required training by POC date.

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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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