374604559-6-26-2023-08-AS-ARAZ-CT6TM8-20230626145043

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604559
Report Date: 06/26/2023
Date Signed: 06/26/2023 02:50:46 PM

Document Has Been Signed on 06/26/2023 02:50 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ROSE'S ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	374604559
ADMINISTRATOR:	SAMORA, YVONNE		FACILITY TYPE:	735
ADDRESS:	1386 STANISLAUS DRIVE		TELEPHONE:	(619) 349-3953
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91913
CAPACITY: 4		CENSUS: 4	DATE:	06/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Administrator Rosemary Wilborn		TIME COMPLETED:	03:10 PM

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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with direct care staff James Wilborn. Administrator Rosemary Wilborn later arrived to meet with LPA. According to the facility’s license, the facility has a maximum capacity of four (4) clients, of which all must be ambulatory. There was a total of four (4) client in care, per physician’s reports all ambulatory.

LPA, accompanied by administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 120 F and bathroom #1 sink was 120 F. Upstairs bathroom was closed due to a repair.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ROSE'S ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 374604559
	VISIT DATE: 06/26/2023

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[CONTINUED FROM LIC 809]

No pools or bodies of water were present. Facility had an empty hot tub in the backyard. Per administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and reviewed multiple staff and client records/files. LPA interview did not raise any licensing concerns. The files which LPA reviewed contained all required documents. Confidential records were stored in locked area.

No deficiencies were cited during today's annual inspection.

An exit interview was conducted with Wilborn to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

LIC809 (FAS) - (06/04)

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