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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604564
Report Date: 05/24/2023
Date Signed: 05/26/2023 09:20:36 AM

Document Has Been Signed on 05/26/2023 09:20 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ROSE'S HOMEFACILITY NUMBER:
374604564
ADMINISTRATOR:MOUSSER, ROSIE A.FACILITY TYPE:
735
ADDRESS:160 BAMBOO LANETELEPHONE:
(951) 375-1662
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 6CENSUS: 6DATE:
05/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:24 PM
MET WITH:Staff, CIndy CosteloTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Janira Arreola and Janette Romero conducted an unannounced annual required visit on 5/24/2023 at 02:24 p.m. LPAs was granted entry and met with Staff, Cindy Costelo, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (3) client present.

The facility is a one story home with (5) bedrooms and (2) bathrooms. No pools or firearms are being kept at the facility. The clients served are adults between the ages of 18-59. LPAs conducted a tour of the interior and exterior and reviewed facility documents. LPA observed the following:

Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The LPAs observed unlocked knife on kitchen counter, as well as unlocked chemicals under the kitchen sink. LPAs also observed alcoholic beverages in the facility fridge that were accessible to residents. Deficiency was cited for this along with plan of correction. The smoke detector and carbon monoxide was operational, and the hot water temperature 108F.



Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility did not meet the required 2-day supply of perishable foods. Deficiency was cited for this along with plan of correction.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. . Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator, possesses a current administrator's certificate.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ROSE'S HOME
FACILITY NUMBER: 374604564
VISIT DATE: 05/24/2023
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Record Review Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification.

An exit interview was conducted where a copy of this report along with deficiency page and appeal rights were provided to the Staff, Cindy Costelo.

This report was lost during a computer error and was final printed and delivered to the licensee on 5/26/2023 after the report was retrieved.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
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Page: 2 of 7
Document Has Been Signed on 05/26/2023 09:20 AM - It Cannot Be Edited


Created By: Janira Arreola On 05/24/2023 at 03:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ROSE'S HOME
FACILITY NUMBER: 374604564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with (1) knife, cleanin supplies, and (5) bottles of ready to drink margaritas in the facility kitchen that were unlocked and accessible to residents. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2023
Plan of Correction
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The licensee agreed have the staff sign a statement of yunderstanding of the section cited aboveby the POC due date.
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.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/26/2023 09:20 AM - It Cannot Be Edited


Created By: Janira Arreola On 05/24/2023 at 03:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ROSE'S HOME
FACILITY NUMBER: 374604564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and ointerview, the licensee did not comply with the section cited above with 2-day perishable food items that were were not in qualntity for (6) residents and (2) live in staff members. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2023
Plan of Correction
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The licensee agreed to send the LPA proof of purchase of perishable items by the POC due date.
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.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023


LIC809 (FAS) - (06/04)
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