374604564-5-29-2025-18-AS-JROO-DH5RBK-20250529125252

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604564
Report Date: 05/29/2025
Date Signed: 05/29/2025 12:53:00 PM

Document Has Been Signed on 05/29/2025 12:53 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 HOME		FACILITY NUMBER:	374604564
ADMINISTRATOR/ DIRECTOR:	MOUSSER, ROSIE A.		FACILITY TYPE:	735
ADDRESS:	160 BAMBOO LANE		TELEPHONE:	(760) 451-6064
CITY:	FALLBROOK	STATE: CA	ZIP CODE:	92028
CAPACITY: 6		CENSUS: 5	DATE:	05/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Licensee, Rosie Mousser		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/29/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Licensee, Rosie Mousser who was informed of the purpose of the visit. The facility has a fire clearance to serve one (1) non-ambulatory and five (5) ambulatory clients. During the visit, LPA observed one (1) staff present and was informed all five (5) clients were attending day program. LPA toured the facility with licensee and observed the facility is made up of a one-story home with three (3) client bedrooms, two (2) bathrooms, a kitchen, dining area, living room and laundry room. Client bedrooms had the required bedding, furniture, and lighting. Bathrooms had grab bars and non-skid mats in the showers. No bodies of water were observed on the premises. Indoor and outdoor pathways were free of obstruction. The facility has a two-day supply of perishable foods and seven-day supply of non-perishable foods. Medications and client files are secured in a locked kitchen cabinet. Licensee tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed a charged fire extinguisher mounted near the kitchen last serviced on 2/1/2025. Staff present has a criminal record clearance and is associated with the facility. Client files reviewed had updated physician's reports and signed admission agreements. LPA reviewed the facility's Fire Drill Log Notes documenting the facility's last fire drill was conducted on 4/21/2025. Clients' personal rights, complaint procedures, and house rules are visibly posted in the dining room. LPA reviewed the Record of Client's/Resident's Safeguarded Cash Resources (LIC 405) for all five (5) clients while licensee counted their physical monies. Licensee reported the LIC 405s were last updated on 5/26/2025 where licensee supervised staff count the clients' physical monies and no discrepancies were discovered. During today's review, LPA and licensee discovered Client 1 (C1) was missing $20 from their monies listed as the total balance. During the visit, licensee reported they contacted staff who was unable to explain the discrepancy.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janette Romero
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 05/29/2025

NARRATIVE

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Upon discovery of the discrepancy, Licensee immediately replaced the $20 and reported staff may have accidentally dropped the $20 during an outing. LPA and licensee began cross-referencing C1's receipts with the "Amount Spent or Withdrawn" category listed in their LIC 405. C1's LIC 405 notes on 5/14/2025 they spent $129 documented as "IKEA delivery receipt". Licensee reported C1 and C2 had furniture delivered together at the facility. LPA reviewed a receipt from IKEA documenting a $129 delivery service fee was paid for electronically. Licensee reported they paid the $129 electronically, but that amount was meant to be divided equally between C1 and C2 since both of their furniture orders were delivered for the one time $129 fee. Licensee added that at the time, C2 did not have enough funds to cover their half so the facility decided to have C1 pay for the entire $129. Licensee reiterated this decision made by the facility was not meant to be punitive against C1. Licensee reported C1 does not have the capacity to manage their funds or consent to paying the full delivery amount. LPA reviewed Title 22 regulation 80026 titled "Safeguards for Cash Resources, Personal Property, and Valuables of Residents" with licensee. Upon review of the regulations, licensee reported moving forward, they will consider loaning the funds to a client pursuant to 80026(e)(1) if a similar situation were to arise. Additionally, C1's LIC 405 documents a total of $21 as amount spent for dining out on 4/30/2025 and 5/18/2025. However when asked, licensee was unable to locate C1's receipts to verify C1's proof of purchases on the 4/30/2025 and 5/18/2025. LPA also reviewed C1's physician report dated 4/3/2025 and the "able to manage own cash resources" row is marked 'no'. Based on the aforementioned, the facility will be cited but licensee has now expressed understanding of requirements under regulation 80026. An exit interview was conducted and a copy of this report LIC 809-D, Appeal Rights, and Confidential Names list (LIC 811) was reviewed and provided to licensee.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janette Romero
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/29/2025 12:53 PM - It Cannot Be Edited

Created By: Janette Romero On 05/29/2025 at 11:49 AM

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: 05/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80026(h)(1)

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by not having receipts as proof of purchase for amounts listed as spent/withdrawn from C1's cash resources which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/27/2025
	Plan of Correction
1 2 3 4	Licensee reported an outside vendor will provide all facility staff, including licensee, training regarding proper management and documentation of client's safeguarded cash resources pursuant to Title 22 regulation 80026. Proof of correction to be submitted to LPA by close of business on 6/27/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:

	Janette Romero
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

LIC809 (FAS) - (06/04)

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