366426422-12-28-2022-56-AS-ACON-CMJUDA-20221228142914

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366426422
Report Date: 12/28/2022
Date Signed: 12/28/2022 02:29:22 PM

Document Has Been Signed on 12/28/2022 02:29 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ROSE GARDEN RESIDENTIAL CARE		FACILITY NUMBER:	366426422
ADMINISTRATOR:	MORGAN E. WILLIAMS		FACILITY TYPE:	740
ADDRESS:	1350 WABASH AVE.		TELEPHONE:	(909) 794-1040
CITY:	MENTONE	STATE: CA	ZIP CODE:	92359
CAPACITY:	63	CENSUS:	DATE:	12/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Cassandra Crowley, Staff Member		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Rose Garden Residential Facility unannounced to conduct an annual inspection with a focus of infection control. LPA approached the business office, staff member opened the door. Before being invited inside, LPA was informed Administrator would like to be present. LPA asked for entry to facility, LPA was granted entry by staff member Cassandra Crowley. LPA stated purpose of the visit. LPA was provided a space to work; then provided a walk through by staff member Mercedes Trujilo. Mercedes reports there are currently no residents suspected or experiencing symptoms of COVID at this time. The current census is 59. Staff informed LPA Administrator is unavailable and will not be able to be present during visit. During the inspection, LPA Coleman conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPA observed appropriate postings throughout the facility, including hand-washing etiquette, face coverings, and COVID-19 symptoms postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). Additional PPE and cleaning supplies are kept secure on grounds in a shed. The facility has a designated infection control to be addressed by the Housekeeping staff. Administrative staff are tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, 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 (CCLD) guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for residents with COVID-19 positive results and/or exposures.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ROSE GARDEN RESIDENTIAL CARE	FACILITY NUMBER: 366426422
	VISIT DATE: 12/28/2022

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The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms. LPA reviewed resident and staff records and interviewed Administrative staff.

12/5/22 Fire Drills are ran on a monthly bases by a company Fire Safety Service, Inc. Last Drill 12/5/22 at 2:54 am Carbon Monoxide Alarms tested and found operational. LPA observed resident rooms, all resident rooms included sufficient furniture and lighting. As well as an attached bathroom with adequate hand soap and paper supplies.

Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected, and no deficiencies were noted.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

LIC809 (FAS) - (06/04)

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