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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604115
Report Date: 01/25/2024
Date Signed: 01/25/2024 02:14:17 PM


Document Has Been Signed on 01/25/2024 02:14 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: 15DATE:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:FACILITY MANAGER, JANETT MOSTERTIME COMPLETED:
02:22 PM
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On January 25, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the required annual inspection and spoke with the Administrator, Val Paraiso, via the telephone. The facility file review was conducted in the Regional Office and additional records were requested and reviewed on site. The facility is licensed for 15 Elderly Adults and operating at a full capacity of 15. LPA met with Facility Manager, Janet Moster.

LPA Mixson toured the facility along with the Facility Manager, Janet and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single-story home, located at 1255 Adventure LN San Marcos, CA 92069. Physical Plant: The facility phone number is (760) 738-9391 and is operable. The LPA observed the resident's bedrooms. The bedrooms were equipped with required furniture as per Title 22, currently at the time of this visit. The LPA inspected facility bathrooms, and the hot water temperature 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. 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 and it was locked. Medications: were reviewed, locked and inaccessible to residents, and there was a 30 day supply. The overall facility is clean, 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 resident in activities and snacks. Records Review: The LPA reviewed staff and resident files and conducted staff and resident interviews. 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 Facility Manager, Janet.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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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