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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425370
Report Date: 07/22/2022
Date Signed: 07/22/2022 12:12:54 PM


Document Has Been Signed on 07/22/2022 12:12 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: 4DATE:
07/22/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Irene ChagollaTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to conduct a health and safety check in relation to complaint control number 56-AS-20220721160710. LPA identified herself to care provider Irene Chagolla. Administrator Manzoor Massey was phoned and LPA discussed the purpose of the visit and the elements of the allegation. Administrator arrived shortly.

Resident in care was present during visit. No imminent health and/or safety concerns observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. LPAs observed sufficient staff present at the facility to provide care.

An exit interview was conducted where this report was discussed and provided to Ms. Chagolla.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
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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