374603373-5-10-2023-08-AS-ARAZ-CRPPB7-20230510110953

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603373
Report Date: 05/10/2023
Date Signed: 05/10/2023 11:10:03 AM

Document Has Been Signed on 05/10/2023 11:10 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	CASA ROSE		FACILITY NUMBER:	374603373
ADMINISTRATOR:	ROSE, MARIA ANGELES		FACILITY TYPE:	735
ADDRESS:	3811 BONITA GLEN TERRACE		TELEPHONE:	(619) 773-7692
CITY:	BONITA	STATE: CA	ZIP CODE:	91902
CAPACITY: 4		CENSUS: 4	DATE:	05/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Licensee Maria Rose		TIME COMPLETED:	11:15 AM

NARRATIVE

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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with administrator Maria “Angie” Rose.

According to the facility’s license, the facility has a maximum capacity of four (4) clients of which all may be non-ambulatory. During today’s inspection, there were a total of four (4) clients in care.

LPA, accompanied by Licensee, toured the interior and exterior of the facility, and inspected each room. 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, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA ROSE	FACILITY NUMBER: 374603373
	VISIT DATE: 05/10/2023

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[CONTINUED FROM LIC 809]

Facility had a swimming pool on premises which was gated and locked. Per administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and reviewed multiple staff and client records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas.

During today’s visit, LPA observed via measurement with a thermometer device, that hot water temperature at taps accessible to clients were non-compliant. Water from the kitchen sink reached 150 F. Water in bathroom #1 and #2 reached 147 F. (Per regulation, hot water temperature at taps accessible to clients is required to be between 105 F and 120 F.) Interviews of staff did not reveal evidence of any client suffering an actual adverse health consequence as a result of hot water at the facility.

A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Rose to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

An exit interview was conducted with Rose, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/10/2023 11:10 AM - It Cannot Be Edited

Created By: Alyssa Ramirez On 05/10/2023 at 10:56 AM

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: CASA ROSE	FACILITY NUMBER: 374603373
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and measurement, the licensee did not comply with the section cited above for 4 of 4 clients [Clients #1 through #4], which posed an immediate safety risk to persons in care.
	POC Due Date: 05/19/2023
	Plan of Correction
1 2 3 4	Licensee will adjust water temperature to be in compliance (105 F- 120 F). Licensee will notify LPA once water temperature is in compliance so that LPA may return to facility to confirm.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Simon Jacob

LICENSING EVALUATOR NAME:

Alyssa Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC809 (FAS) - (06/04)

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