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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425370
Report Date: 01/26/2023
Date Signed: 01/26/2023 10:27:03 AM


Document Has Been Signed on 01/26/2023 10:27 AM - 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 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:
01/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:MANZOOR R. MASSEY, LICENSEETIME COMPLETED:
10:35 AM
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On 1/26/2023 at 9:33 a.m., Licensing Program Analysts (LPAs) Magda Malcore and Rayshaun Nickolas conducted an unannounced PCC visit. LPAs Malcore and Nickolas met with Caregiver Bruce Hernandez and were granted entry. Facility staff called Licensee Manzoor Massey who arrived approximately 15 minutes later.

No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was provided to Massey.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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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