374604559-1-9-2024-08-AS-DNGN-CZC3PJ-20240109172536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604559
Report Date: 01/09/2024
Date Signed: 01/09/2024 05:26:51 PM

Document Has Been Signed on 01/09/2024 05:26 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 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:	01/09/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Administrator Rosemary Wilborn and Licensee Yvonne Samora		TIME COMPLETED:	05:45 PM

NARRATIVE

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Licensing Program Analysts (LPA) Dang Nguyen and Juliana Barfield conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Administrator Rosemary Wilborn. LPAs also met with Licensee Yvonne Samora, who arrived later during the visit.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 01/06/2024), regarding Client #1 (C1) being a missing person. [See LIC 811 Confidential Names List for a description of C1.]

During today’s visit, LPAs performed a brief facility tour. At the time of LPA’s visit, C1 was not present at the facility. LPAs performed a welfare check on the other three clients in care, which revealed no immediate safety concerns. LPAs also collected copies of pertinent care records and interviewed relevant staff.

According to C1’s latest LIC602 Physician’s Report (dated 04/06/2023), C1’s doctor determined that that C1 was ambulatory, able to safely leave the facility unassisted, able to communicate well, and independent in personal care tasks beyond medication assistance. San Diego Regional Center (SDRC) records corroborated the above and showed that C1 also knew how to use public transportation, was mindful of traffic safety as a pedestrian, and knew how to operate their cell phone.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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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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: 01/09/2024

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[CONTINUED FROM LIC 809]

Records review and staff interviews showed: On the afternoon of 01/04/2024, C1 signed themselves out and left the facility with their cell phone. When staff noticed C1 had not returned to the facility later that same night, staff called C1’s cell phone several times, but C1 did not answer it. On the morning of 01/05/2024, License notified local law enforcement that C1 was considered missing. C1 briefly returned to the facility unharmed (as witnessed by multiple staff) around 7:30 PM on 01/08/2024, before leaving again. As of 01/09/2024, C1 had not returned to the facility but phoned facility staff to say that they were safe.

Licensee had a written Absentee Notification Plan as part of C1’s record of care, and staff followed it. Licensee met reporting requirements during the incident and provided timely updates to local law enforcement. Licensee also reported C1's missed medication doses to their prescribing doctor and SDRC.

No deficiencies were cited during today’s visit.

An exit interview was conducted with Samora and Wilborn, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

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