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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604115
Report Date: 06/21/2022
Date Signed: 06/21/2022 05:10:44 PM


Document Has Been Signed on 06/21/2022 05:10 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,
, CA



FACILITY NAME:COUNTRY ROSE ESTATE MEMORY CAREFACILITY NUMBER:
374604115
ADMINISTRATOR:PARAISO, CATHERINE TFACILITY TYPE:
740
ADDRESS:1255 ADVENTURE LNTELEPHONE:
(760) 738-9391
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY:15CENSUS: 14DATE:
06/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator, Val ParaisoTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Sabel Martinez, conducted a complaint investigation visit in which an unrelated deficiency was noted. The LPA was greeted by Caregiver, Esmeralda Pancho, identified himself, and disclosed the purpose of the visit. Administrator, Val Paraiso, arrived during the visit.

During today's visit, the following deficiency was noted: Caregiver S1 was observed to be working at the facility. Interviews with staff and administrator confirmed the S1 has been working at the facility for approximately over one months. A check of CCLD systems revealed that S1 does not have a criminal record clearance with the Department.

Per California Code of Regulations, Title 22, the following deficiency is cited and listed on LIC 809-D. An immediate civil penalty of $500 was assessed today for Criminal Record Clearance violation on form LIC 421-BG.

An exit interview was conducted with Administrator, Val Paraiso, to whom a copy of this report, LIC 421-BG, and Licensee's Rights (LIC 9058 01/16) were provided to.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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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Document Has Been Signed on 06/21/2022 05:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: COUNTRY ROSE ESTATE MEMORY CARE
FACILITY NUMBER: 374604115

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2022
Section Cited

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87355 Criminal Records Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
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This requirement was not met as evidenced by: Based on observations, interview and systems review, the licensee did not ensure S1 had a CA criminal record clearance prior to working in the licensed facility which posed an immediate safety risk to 14 of 14 clients in care.
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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: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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