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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425370
Report Date: 02/10/2023
Date Signed: 02/10/2023 03:52:26 PM


Document Has Been Signed on 02/10/2023 03:52 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
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:
02/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Regina Albudriz, leadTIME COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Anna Bueno and Michelle Echeverria conducted an unannounced visit to this facility to continue investigation of complaint number: 56-AS-20230103155228. LPAs met with lead staff Regina Albudriz.

During today's visit, LPAs reviewed pertinent records and interviewed staff and witness. While reviewing medication and medication records, LPAs found the following issues:
  • Two medications expired on 10/2022 and 11/2022 are kept with current medication
  • 5 monthly pill boxes were observed with 1 pill box containing medications.
These pose an immediate health and safety risk to residents in care. Refer to LIC 809D for deficiencies cited.

An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to Janet Oliver
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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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Document Has Been Signed on 02/10/2023 03:52 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
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: 02/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2023
Section Cited

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Incidental Medical and Dental Care: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement was not met as evidenced by:
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Licensee shall immediately conduct an audit of all current medications for all current residents and conduct training on medication administration as noted in CCR section 87465.
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LPAs and lead staff observed one pill box with pills inside days marked TUE, WED, THU.
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Proof of correction shall be submitted to LPA no later than end of POC date.
Type A
02/14/2023
Section Cited

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Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy...or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years...
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Licensee shall immediately conduct an audit of all current medications for all current residents and destroy non current medications or medications with no active prescriptions in accordance to CCR section 87465(i)
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This requirement is not met as evidenced by:

LPAs and lead staff observed exipred as needed medication in resident's basket mixed with current medications.
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Proof of correction shall be submitted to LPA no later than end of 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
LIC809 (FAS) - (06/04)
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