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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604115
Report Date: 01/13/2025
Date Signed: 01/13/2025 01:55:20 PM

Document Has Been Signed on 01/13/2025 01:55 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:COUNTRY ROSE ESTATE MEMORY CAREFACILITY NUMBER:
374604115
ADMINISTRATOR/
DIRECTOR:		PARAISO, CATHERINE TFACILITY TYPE:
740
ADDRESS:1255 ADVENTURE LNTELEPHONE:
(760) 738-9391
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY: 15TOTAL ENROLLED CHILDREN: 0CENSUS: 15DATE:
01/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Administrator, Val ParaisoTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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On 1/13/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator, Val Paraiso who was informed of the purpose of the visit. The facility is licensed to serve fifteen (15) non-ambulatory elderly residents. The facility also has an approved hospice waiver for six (6) residents and is approved for a secured perimeter.

LPA toured the facility's interior and exterior with Administrator. During the tour, LPA observed the facility is made up on a one-story building with eleven (11) resident bedrooms, seven (7) restrooms, a kitchen, dining room, and living room. Indoor and outdoor passageways are free of obstructions. There are no bodies of water on the premises. Outdoor shaded seating is available for the residents. LPA toured the kitchen and observed the facility has more than a two-day supply of perishable foods and seven-day supply of non-perishable food items. Medications are secured in a locked cabinet inside Administrator's office. Staff present have a criminal record clearance. Administrator tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA was present during a phone call between Administrator and their alarm company, ADT Security, who confirmed the facility's smoke alarms and carbon monoxide detectors are currently interconnected. LPA also observed charged fire extinguishers mounted throughout the facility, which were last serviced on 7/23/2024. Administrator reported by summer of 2025, the facility's driveway will be paved to facilitate fire department apparatus' access to the facility. Administrator also reported they plan to renovate the facility and are aware they must obtain building permits prior to any construction/alteration of the facility. LPA reviewed the facility's annual fire inspection dated 5/9/2024 conducted by San Marcos Fire Department. The facility was cited for not having illuminated exit signs or a five (5) year fire sprinkler certification. During today's visit, LPA observed all exit signs were illuminated and the facility's annual fire sprinkler certification was completed in July 2024. During the visit, Administrator was unable to locate the facility's current five (5) year sprinkler certification to prove correction of fire inspection violation. As a result, the facility will be cited. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator along with LIC809-D and Appeal Rights.
Tricia DanielsonTELEPHONE: (951) 202-5067
Janette RomeroTELEPHONE: (951) 529-2930
DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/13/2025 01:55 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not possessing/producing copy of a current five (5) year sprinkler certification, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
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Licensee agreed to obtain a five (5) year sprinkler certification and provide proof of correction to LPA by close of business on 1/27/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Tricia DanielsonTELEPHONE: (951) 202-5067
Janette RomeroTELEPHONE: (951) 529-2930

DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2025

LIC809 (FAS) - (06/04)
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