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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603871
Report Date: 01/10/2024
Date Signed: 01/10/2024 12:36:25 PM


Document Has Been Signed on 01/10/2024 12:36 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
RIVERSIDE, CA 92507



FACILITY NAME:ROSE GARDENFACILITY NUMBER:
374603871
ADMINISTRATOR:CORPUZ, ROLANDOFACILITY TYPE:
740
ADDRESS:1266 PLEIADES DRTELEPHONE:
(760) 659-6397
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:15CENSUS: 15DATE:
01/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:ADMINISTRATOR, ROLANDO CORPUZTIME COMPLETED:
12:48 PM
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On January 10, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the required annual inspection and met with the Administrator, Rolando. The facility file review was conducted in the office and additional forms were reviewed on site.

LPA Mixson toured the facility along with the Administrator, Rolando and inspected the facility inside and outside. There were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single multi structure story home, located at 1266 Pleiads Dr, CA 92084. Physical Plant: The facility phone number is (760)659-6397 and is operable. The LPA observed the residents bedrooms, and they are equipped with required furniture as per Title 22. The LPA inspected facility bathrooms, and the hot water temperature was tested and tested within regulations. The bathrooms were clean and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The LPA observed required postings such as "If you See Something, Say Something" the "Personal Rights" and the Ombudsman postings were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the resident and staff files. The closet was locked and inaccessible to residents in care. Medications: were reviewed, locked and inaccessible to residents, and there was a 30 day supply for each resident receiving medication. The overall facility is clean and the furniture is in good condition. The facility heating system and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly. Care & Supervision Facility has sufficient staff, four staff at the time of this visit and the staff were engaging the residents in medication and meals. Records Review: The LPA reviewed five resident files, and three staff files, and conducted three staff interviews, and no resident interviews due to meal time and medications being passed. Previous Community Care Licensing forms were reviewed. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit. An exit interview was conducted and a copy of this report was given to the Administrator, Rolando Corpuz.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
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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