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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604564
Report Date: 05/26/2023
Date Signed: 05/26/2023 10:44:24 AM

Document Has Been Signed on 05/26/2023 10:44 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:
05/26/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Licensee, Rosie MousserTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual continuation 5/26/2023 at 9:06 a.m. LPA was granted entry and met with Licensee, Rosie Mousser, who was informed of the purpose of the visit. At the time of the visit there was (3) staff and (3) clients present.

LPA conudtced client and staff interviews, and observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.



Record Review and Resident Files: Two (2) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in medication cabinet. LPA reviewed client medications for (2) client and reviewed medication lists on MARS. All medication was found to be administered and all required labeling was in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan, the plan met the department standards. LPA reviewed documentation showing the facility's last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit with all required items.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to the Licensee, Rosie Mousser.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
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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