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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602232
Report Date: 03/07/2025
Date Signed: 03/07/2025 03:20:35 PM

Document Has Been Signed on 03/07/2025 03:20 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ROSELAND IIFACILITY NUMBER:
374602232
ADMINISTRATOR/
DIRECTOR:		TIMOTHY CARRASCOFACILITY TYPE:
735
ADDRESS:1262 DIXON WAYTELEPHONE:
(619) 426-6357
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 5DATE:
03/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Timothy "TJ" Carrasco and Licensee Liberty Cruz NelsonTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Timothy "TJ" Carrasco. LPA also met with Licensee Liberty Cruz Nelson, who arrived shortly after.

According to the facility’s license, the facility has a maximum capacity of six (6) clients, of whom all must be ambulatory. According to LIC602 Physician’s Reports, staff interviews, and LPA observation: During this annual inspection, there were a total of five (5) clients in care, of whom all were ambulatory, per their respective doctors. The facility’s license did not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present.

During this inspection, LPA interviewed multiple clients and staff. LPA reviewed the care and administrative records for all clients and the personnel and training files for all active staff. The files reviewed were complete/complaint. LPA also toured the interior and exterior of the facility and inspected all common areas and bedrooms. In the facility’s kitchen, LPA observed unlocked/unsecured: one (1) sharp cooking knife with an approximately eight-inch metal blade, and one (1) pair of sharp scissors. In the facility’s backyard, LPA observed unlocked/unsecured: one (1) large spade tool with a rusted metal blade that was roughly eight-inches long by eight-inches wide, and one (1) loose piece of rusted metal rebar around 1.5 feet long.

The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens, hygiene, and Personal Protective Equipment (PPE) supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2025
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 03/07/2025 03:20 PM - It Cannot Be Edited


Created By: Dang Nguyen On 03/07/2025 at 01:37 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ROSELAND II
FACILITY NUMBER: 374602232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not ensure some items that could pose a danger if readily available to clients were stored where inaccessible to clients. This posed an immediate health and safety risk to 5 of 5 clients (Client #1 through Client #5) in care.
POC Due Date: 03/07/2025
Plan of Correction
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During today's visit, LPA and staff immediately secured/locked the hazardous items referenced in the report, resolving the immediate risk. Licensee agreed to retrain all staff on what items constitute safety hazards to clients, and their expectation that they remain locked away when not in active use by staff. Licensee agreed to E-mail the training sign-in sheet to LPA, by 04/07/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2025


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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ROSELAND II
FACILITY NUMBER: 374602232
VISIT DATE: 03/07/2025
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[CONTINUED FROM LIC 809]

The facility’s ambient internal temperature was complaint at 73 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen Sink was 116.4 F, Bathroom #1 Sink was 115.7 F, Bathroom #2 Sink was 115.5 F, and Bathroom #3 Sink was 118.8 F. Appliances to preserve perishable food were also complaint in temperature: Kitchen and Garage Refrigerators were both 39 F, and Kitchen and Garage Freezers were both 0 F. There were at least (2) days of perishable food and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present and in good condition.

The facility’s pond (which was empty of water) was also fenced and locked. The facility’s fireplace was screened, as required. There were no open-faced heaters accessible to clients. Smoke detectors, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. The facility's fire extinguishers were all serviced within the last twelve (12) months. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Per the Licensee, no firearms or ammunition were kept at the facility. Licensee presented proof of current business liability insurance and surety bond.

One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC809-D page). A Plan of Correction was jointly developed with the Licensee.

LPA issued one (1) Technical Violation (TV) regarding needing to vary the type of disaster to be drilled each quarter with staff (refer to the LIC9102-TV page). LPA also provided Technical Assistance (TA) regarding refresher training for staff on California Mandated Reporting requirements and on staff auditory devices on exit doors (refer to the LIC9102-TA pages).

An exit interview was conducted with Liberty Nelson, to whom a copy of this report, the LIC 809-D page, the LIC9102-TV page, the LIC9102-TA page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today's visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC809 (FAS) - (06/04)
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