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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604559
Report Date: 08/19/2022
Date Signed: 08/19/2022 02:47:26 PM

Document Has Been Signed on 08/19/2022 02:47 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ROSE'S ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
374604559
ADMINISTRATOR:SAMORA, YVONNEFACILITY TYPE:
735
ADDRESS:1386 STANISLAUS DRIVETELEPHONE:
(619) 349-3953
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 4CENSUS: 5DATE:
08/19/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:54 PM
MET WITH:Yvonne Samora, LicenseeTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an announced visit to conduct a post-licensing inspection to ensure that the facility is operating in compliance with California Code of Regulations, Title 22, Division 6. LPA introduced self, disclosed the purpose of the visit and was granted entry into the facility by Yvonne Samora, Licensee.

A tour of the facility was conducted inside and out. LPA conducted a general overall inspection, which included, but was not limited to, infection control protocols.

During today's inspection LPA observations include the following: Symptom screening procedures for staff, clients and visitors; posted signs regarding visitor policy, promoting hand washing, cough and sneeze etiquette and other infection control procedures; testing plan and procedures was discussed; plans for containing infections, PPE supplies procedures and training; and disinfection procedures.

All indoor and outdoor passageways were free from obstructions. The facility’s indoor temperature was 76 degrees Fahrenheit (F). No bodies of water were observed. According to Licensee Samora there are no firearms or ammunition stored in the facility. The kitchen sink measured at 118.2 degrees F; the downstairs bathroom water measured at 117.7 degrees F; the upstairs bathroom water measured at 112.3 degrees F. Cleaning supplies and toxins were locked in the garage, inaccessible to the clients. Additional chemicals were stored in the locked laundry room. LPA toured resident bedrooms. The rooms had the required furnishings and sufficient lighting. Licensee provided the clients with clean linens, in good repair, and sufficient hygiene products for personal use. The facility had functioning carbon monoxide detectors and smoke detectors that met statutory regulations.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ROSE'S ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 374604559
VISIT DATE: 08/19/2022
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A one week’s non-perishable and a two day of perishable food supply is maintained on the property. All food was properly stored and made available to clients. Additional food supply is stored in a refrigerator in the garage. Medications were observed to be in a locked cart that is inaccessible to clients.

Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with Licensee Samora. A copy of this report, along with the Applicant Licensee Rights (01/2016) was provided to Licensee Samora at the conclusion of the visit. The signature provided below is confirmation that the documents were received.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC809 (FAS) - (06/04)
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