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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425370
Report Date: 06/06/2022
Date Signed: 06/06/2022 04:07:02 PM


Document Has Been Signed on 06/06/2022 04:07 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:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Irene ChangollaTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Anna Bueno and Rayshaun Nickolas conducted an unannounced visit to the facility to conduct a required annual inspection with an emphasis on infection control. LPAs identified themselves to care staff Irene Changolla. Staff verified that the facility currently has no active and/or suspected COVID-19 cases. Licensee Manzoor Massey was phoned by staff during the visit.

During the inspection, LPA Bueno interviewed care staff regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA did not observe appropriate postings in the facility, including COVID-19 symptoms and infection control postings, which were in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

During the inspection, LPAs did not observe PUB 475, CCLD complaint poster. LPAs observed live pests in the kitchen area. Refer to LIC809-D for deficiencies cited. Technical advisories were provided. Refer to LIC9102As for advisories.

An exit interview was conducted where this report was discussed, and a copy of this report, LIC809D, LIC9102As, and appeal rights were provided to Ms. Changolla at the conclusion of the inspection.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
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 8


Document Has Been Signed on 06/06/2022 04:07 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: ROSE VILLA
FACILITY NUMBER: 366425370

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and records review, the licensee did not comply with the section cited above as LPAs observed live pests in the kitchen area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2022
Plan of Correction
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Licensee shall provide to the Department proof of service on 5/27/2022 and proof of re-occurring service for the pests found today, 6/6/2022.
Type B
Section Cited
CCR
87246(c)(2)(a)
Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations, the licensee did not comply with the section cited above as PUB 475 was not posted in the facility which poses a potential safety or personal rights risk to persons in care.
POC Due Date: 06/15/2022
Plan of Correction
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Licensee shall provide proof of PUB475 posting in the facility.

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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
LIC809 (FAS) - (06/04)
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