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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604564
Report Date: 05/31/2024
Date Signed: 05/31/2024 03:07:04 PM

Document Has Been Signed on 05/31/2024 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ROSE'S HOMEFACILITY NUMBER:
374604564
ADMINISTRATOR/
DIRECTOR:		MOUSSER, ROSIE A.FACILITY TYPE:
735
ADDRESS:160 BAMBOO LANETELEPHONE:
(951) 375-1662
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 6CENSUS: 5DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:59 PM
MET WITH:Rosie Mousser Administrator TIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Javina George conducted an unannounced visit to the facility for the purpose of conducting a 1 year required visit/annual inspection. LPA George met with Caregiver Catherine Palado and explained purpose of today's visit. The Administrator Rosie Mousser arrived shortly after. Below is a summary of what was observed during today’s inspection:

Infection Control: LPA observed that the facility has an updated Infection Control Plan on file dated 3/4/22. The facility and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents as evidenced by practicing good hand hygiene.

Physical Plant: LPA toured the interior and exterior of the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. The facility was observed to have the required furniture and linen to be present and in good condition in resident bedrooms. The exits are not obstructed and that there is plenty of space for activities. There are no pools or bodies of water on the premises. There is a shed in the backyard that is being used for storage.

Staff Records review: LPA observed that there are sufficient staff present to meet the needs of residents. The facility does not have a required ratio per the Administrator. LPA observed for the two staff Staff #1 (S1) and Staff #2 (S2) present at the facility to have obtained criminal record clearance but were not associated to the facility. Deficiency cited and $500 civil penalty for each staff is being issued. Staff present at facility current CPR/First Aid Certification that do not expire until March 2026. The Administrator certificate expires on 10/13/24.

Resident Record reviews: A review of 3 residents files to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Individual Program Plan (IPP). In addition, the resident’s Personal and Incidental (P&I) funds were verified and had the amount that was indicated on the P&I form was present.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ROSE'S HOME
FACILITY NUMBER: 374604564
VISIT DATE: 05/31/2024
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Food Services: The kitchen and dining area to be maintained in a clean and healthful manner. LPA George observed the facility to have the required amount of 7 day supply non-perishable and a two supply perishable food items.

Medication: Resident medication was observed to be locked in a file cabinet and inaccessible to residents. A review of medication revealed that the medication is being given as prescribed as evidenced by the Medication Authorization Record (MAR) and medication (bubble packs).

Emergency Disaster Preparedness: The facility conducts disaster drills on a quarterly basis. The last drill was conducted on 4/20/24. The smoke and carbon monoxide detectors were tested and were found to be operable. The facility has 2 fully charged fire extinguishers. There are no known guns or ammunition on the premises. The hot water was tested and was found to be within regulatory limit measuring at 109-113 degrees Fahrenheit. The facility has emergency food and water supply. The sharps and hazardous chemicals were observed to be locked and inaccessible to residents in care.

Based on today's inspection a citation will be issued on the attached 809D in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 6).

An exit interview was conducted and a copy of this report, 809D, LIC421BG, appeal rights and LIC9098-Proof of Corrections form was provided to Administrator Rosie Mousser.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/31/2024 03:07 PM - It Cannot Be Edited


Created By: Javina George On 05/31/2024 at 02:29 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: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(12)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 ot of 2 times as S1 and S2 had obtained criminal record clearance but are not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2024
Plan of Correction
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The Licensee agrees to associate both S1 and S2 to the facility. Proof of POC is to be submitted to the department by 5pm on the due date indicated 6/1/24.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
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