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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604115
Report Date: 11/29/2022
Date Signed: 11/29/2022 12:17:20 PM


Document Has Been Signed on 11/29/2022 12:17 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: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: 11DATE:
11/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Val ParaisoTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to follow up on a recent incident that occurred at the facility. LPA met with Administrator, Val Paraiso who was informed of the purpose of the visit.

The regional office received a police report from an incident that occurred at the facility on 11/02/2022 between Resident (R1) and Resident 2 (R2). The police report from the San Marcos station details that the administrator called the police after R1 struck R2 with a cane.

LPA reviewed resident records for Resident 1 (R1) and Resident 2 (R2) and took statements from the administrator. R1 is no longer residing at the facility and was the former roommate of R2. On 10/27/2022 R1 struck R2 on the shin, staff was able to separate the residents. The physician and responsible party were contacted, as R1 did not have a history of physical aggression. This was evidenced by R1's plan of care and preappraisal. On 11/2/2022 R1 was found by staff next to R2, verbalizing that they would strike R2. The administrator was able to separate R1 and removed the cane from R1. Staff called the police, who took a report, but were unable to 51/50 R1. R1's responsible party was looking for alternate placement after the incident as reported by the administrator. On 11/4/2022 staff was sitting next to R1 in the living room when R1 struck R2. Staff was able to separate the residents. On this date R1 was moved out of the facility by their responsible party. Based on the on records reviewed, and interview with administrator it was found that the facility was providing sufficient care and supervision for R1 and R2.

No deficiencies were cited at the time of the visit

An exit interview was conducted where this report was reviewed and provided to Administrator, Val Paraiso.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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