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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600883
Report Date: 03/22/2024
Date Signed: 03/22/2024 11:02:02 AM

Document Has Been Signed on 03/22/2024 11:02 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ROSEL'S HOMEFACILITY NUMBER:
415600883
ADMINISTRATOR:JOHN RUZZEL SKAGGSFACILITY TYPE:
735
ADDRESS:2033 OREGON AVENUETELEPHONE:
(650) 387-9488
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 4CENSUS: 4DATE:
03/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Co Licensee/Administrator - Romar RaquinilTIME COMPLETED:
11:15 AM
NARRATIVE
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On 03/22/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management deficiencies visit. LPA met with Co Licensee/Administrator - Romar Raquinil and explained the purpose of today's visit.

This visit is a follow up visit in relation to a complaint received on 08/21/2023 complaint #14-AS-20230821165002. Findings to these allegations were delivered on 12/20/2023. An additional citation is issued as a result of the investigation's findings on the following LIC809D page.

The deficiencies for the substantiated allegations are cited in accordance with California Code of Regulations, Title 22, Division 6 and is noted on attached LIC809D. Immediate Civil Penalty of $500 is assessed for a violation resulting in serious bodily injury. The facility was informed that additional civil penalties may be assessed. Report is reviewed with Co Licensee/Administrator - Romar Raquinil and a copy is provided with appeal rights. A copy of the civil penalty will be provided
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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Document Has Been Signed on 03/22/2024 11:02 AM - It Cannot Be Edited


Created By: Jaime Vado On 03/21/2024 at 05:28 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ROSEL'S HOME
FACILITY NUMBER: 415600883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2024
Section Cited
CCR
80072(a)(3)

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80072(a)(3) Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This regulation has not been met as evidenced by:
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The licensee shall develop a plan of correction adressing this regulation and developing a plan ensuring that this regulation shall be followed in the future.
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Based on investigation interviews it was found that S1 punched the resident in the stomach area which resulted in brusing to the body. The resident was not free from from corporal or unusual punishment or infliction of pain.
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Civil penalty is assesed on this day at $500 for a serious bodily injury as a result of a staff member punching a resident causing bruising.

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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:April Cowan
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
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