<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426422
Report Date: 03/01/2024
Date Signed: 03/01/2024 01:25:47 PM

Document Has Been Signed on 03/01/2024 01:25 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 CAREFACILITY NUMBER:
366426422
ADMINISTRATOR:DANICA TURNERFACILITY TYPE:
740
ADDRESS:1350 WABASH AVE.TELEPHONE:
(909) 794-1040
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY: 63CENSUS: 3DATE:
03/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:David Monroy VIP OperationsTIME COMPLETED:
01:40 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 (LPA) Mary Rico conducted an unannounced visit to the facility for a complaint 56-AS-20231226104943. During the complaint visit, LPA Rico completed a case management visit to cite for one (1) deficiency found during facility tour.

During a facility tour, LPA Rico observed resident’s patio fence door not open and closed properly. When LPA Rico open the fence door, the fence began titling to the side.

During today’s visit, one (1) Type A deficiency to the facility were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report, LIC809, LIC809D, Appeal Rights were discussed and provided to David Monroy VIP Operations
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2024
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 2
Document Has Been Signed on 03/01/2024 01:25 PM - It Cannot Be Edited


Created By: Mary Rico On 03/01/2024 at 12:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ROSE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 366426422

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2024
Section Cited
CCR
87303(a)

1
2
3
4
5
6
7
87303 Maintenance and Operation (a) The facility shall be clean, safe and sanitary and in good repair at all times. Maintenance shall include ... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will send LPA proof the patio fence door has been repaired.
8
9
10
11
12
13
14
Based on observations, the Licensee did not comply with the section cited above by having residents patio fence door in disrepair which poses an immediate health, safety and personal rights risks to residents in care.
8
9
10
11
12
13
14
POC due date 3/4/2024.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2