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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604559
Report Date: 06/19/2024
Date Signed: 06/19/2024 03:07:24 PM

Document Has Been Signed on 06/19/2024 03:07 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 FACILITYFACILITY NUMBER:
374604559
ADMINISTRATOR/
DIRECTOR:
SAMORA, YVONNEFACILITY TYPE:
735
ADDRESS:1386 STANISLAUS DRIVETELEPHONE:
(619) 349-3953
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 6CENSUS: DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Licensee Yvonne SamoraTIME VISIT/
INSPECTION COMPLETED:
03:30 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 Assistant Administrator Rosemary Wilborn. Licensee Yvonne Samora later arrived to meet with LPA. According to the facility’s license, the facility is licensed for six (6) ambulatory clients. There was a total of three (3) clients in care.

LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each client bedroom. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Extra linens and hygiene supplies were present. Hot water temperature was in compliance.

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. Facility has an empty hot tub on premises. No other pools or bodies of water present.

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher and first aid kit present. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff/clients and reviewed multiple staff/client files. The files which LPA reviewed contained all required documents.

No deficiencies were cited during today's annual inspection.

An exit interview was conducted with Licensee 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: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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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