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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425370
Report Date: 03/17/2022
Date Signed: 03/17/2022 02:42:52 PM


Document Has Been Signed on 03/17/2022 02:42 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, 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: 5DATE:
03/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Licensee, Manzoor MasseyTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to conduct additional interviews and gather documents pertinent to complaint control number 18-AS-20220126143226. LPA was met by staff who phoned licensee Manzoor Massey.

LPA toured the facility, conducted resident interviews, and reviewed facility files. LPA observed three residents in their rooms and a resident receiving outside health services. During this visit, LPA did not observe imminent health & safety concerns.

The licensee was advised that the investigation is still open. Additional time is needed to complete this investigation.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the licensee.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
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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