Rosehaven 1

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Rosehaven I. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, of which one may be bedridden. Facility has an approved hospice waiver for 5 residents and the home currently has 4 residents with 2 on hospice during today's visit. Administrator Jaya Pichika has submitted the administrator certificate renewal as of March 5, 2026. LPA Lyman along with Caregiver Larry Espansol toured the facility at 8:34 AM. Administrator Jaya Pichika arrived during the visit. LPA toured the physical plant, checked food service, reviewed records and the first aid kit. Facility appears to be clean, safe, and sanitary. The home consists of six resident bedrooms, one resident restroom, two common restrooms, one staff room, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed one resident with half bed rails and one with full bed rails. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 122 and 125.2 degrees F in all facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. The entry door into the garage is secured. LPA observed a locked storage area for cleaning supplies. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. CONT ON LIC809-C DATED 04/23/2026 LPA toured the outside grounds and there is ample shaded seating for residents. LPA observed ample emergency food supply. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 02/20/2026 and drills are conducted quarterly. Facility provides activities in the form of exercise and games. At 9:15 AM, LPA reviewed four resident files and three staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Residents 1 and 4 do not have a current medical assessments in the file. Two out of three staff do not have current CPR/ First aid training. LPA reviewed medication storage and administration. Medications are stored in a locked cabinet and appear to be administered per physician order. Facility has a annual licensing fee due on 05/20/2026. Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.the state’s words, verbatim · CDSS document, Apr 23, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 05/09/2025. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. *Deficiency cited under Health and Safety Code 1569.625(b)(2) pertaining to Training has been cleared. Licensee provided proof of correction. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87412(a) pertaining to Personnel Records has been cleared. Licensee provided proof of correction. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87303(a) pertaining to Maintenance and Operation has been cleared. Licensee corrected noted items. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87203 pertaining to Fire safety has been cleared. Smoke detectors are operational during today's visit. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87463(h)(1) pertaining to Reappraisals has been cleared. Licensee provided proof of correction. *Deficiency cited under Title 22 Regulation 87608(a)(3) pertaining to Postural Supports has been cleared. Licensee provided proof of correction. Licensee has been advised to maintain all items in compliance with Title 22 regulations. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 16, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Rosehaven I. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, of which one may be bedridden. Facility has an approved hospice waiver for 5 residents and the home currently has 3 residents with none on hospice during today's visit. Administrator Jaya Pichika has a current administrator certificate expiring on 09/13/2025. LPA Lyman along with Caregiver Larry Espinol toured the facility at 10:58 AM. Administrator Jaya Pichika arrived during the visit. LPA toured the physical plant, checked food service, reviewed records and the first aid kit. Facility appears to be clean, safe, and sanitary. The home consists of six resident bedrooms, one resident restroom, two common restrooms, one staff room, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed two residents with a half bed rails. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. At 11:05 AM, LPA observed there are missing drawer pulls in the master restroom. Water temperature measured between 109.4 and 111 degrees F in all facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. The entry door into the garage is secured. LPA observed a locked storage area for cleaning supplies. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. Four out of six smoke detectors are inoperable. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. CONT ON LIC809-C DATED 05/09/2025 LPA toured the outside grounds and there is ample shaded seating for residents. At 11:15 AM, LPA observed the exit gate does not latch shut. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 04/25/2025 and drills are conducted quarterly. Facility provides activities in the form of exercise and games. At 11:30 AM, LPA reviewed three resident files and three staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Resident 2 does not have a current medical assessment in the file and two out of two residents with bed rails do not have a physician order for rails. One out of three staff do not have a personnel file and three out of three staff do not have current training. LPA reviewed medication storage and administration. Medications are stored in a locked cabinet and are being administered per physician order. Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.the state’s words, verbatim · CDSS document, May 9, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 07/19/2024 and 09/18/2024. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87303(a) pertaining to Maintenance and Operation has been cleared. Licensee provided proof of correction. Licensee has complied with the terms of the POC. Licensee has been advised to maintain all items in compliance with Title 22 regulations. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 4, 2024

Type of visit: Office

Licensing Program Manager (LPM) Alisa Ortiz, and Licensing Program Analyst (LPA) Kimberly Lyman, conducted an informal office meeting with Licensee Jaya Pichika to discuss general compliance concerns at the facility. The following items were discussed during the meeting: Staffing levels and schedule. Physical plant issues. Lack of communication between licensee and the department. Non-compliance with citations. Licensing fees Reporting requirements Licensee agrees as follows: Licensee to communicate with the department on all issues or concerns regarding facility operations. Licensee agrees to contact department for clarification and not make assumptions. Licensee to forward a copy of the LIC 500 to LPA by 10/14/2024 that ensures coverage during hours when residents require services. Facility will maintain compliance of Title 22 at all times and failure to maintain compliance may result in the department taking further action. During the visit, Licensee was offered technical support services with the department and Licensee agreed to a referral for the service. Exit interview conducted and a copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Oct 11, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 09/18/2024. LPA was greeted and granted entry into the facility by Licensee/ Administrator Jay Pichika and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87355(e)(1) pertaining to Criminal Background Clearance has been cleared. Licensee provided proof of correction. Licensee has complied with the terms of the POC. Licensee has requested an extension to correct the following items: Renovation of master bathroom shower Repair of kitchen cupboard Repair of flooring in entryway. LPA has granted an extension to repair remaining items until 10/10/2024. Licensee has been advised of meeting in Orange County Regional Office on 10/11/2024 at 10:00 AM. Licensee has been advised to maintain all items in compliance with Title 22 regulations. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 30, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 07/19/2024. LPA was greeted and granted entry into the facility by Caregiver Marinell Bautis and explained the reason for the visit. Jay Pichika arrived during the visit. *Deficiency cited under Title 22 Regulation 87303(a) pertaining to Maintenance and Operation has been cleared. Licensee cleared noted items. Licensee has complied with the terms of the POC. *Deficiency cited under H & S Code 1569.626(a)(1) pertaining to Dementia Training has been cleared. Licensee provided proof of training.. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87467(a)(1) pertaining to Care Plans has been cleared. Licensee provided proof of correction.. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87411(c)(1) pertaining to CPR has been cleared. Licensee provided proof of correction. Licensee to provide documented plan of completion for renovation by 09/23/2024. Licensee has been advised to maintain all items in compliance with Title 22 regulations. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 18, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with a plan of correction visit (POC). LPA was greeted and granted entry into the facility and explained the reason for the visit. Upon entry, LPA observed two staff present are not cleared or associated to facility. During the POC visit, LPA observed a broken kitchen cupboard, tile buckling on floor by front door, and a large pile of debris in the yard. LPA consulted with Licensee regarding staffing. Licensee indicates two staff will be arriving in the evening to work. LPA verified that both staff are cleared and associated to the facility. Licensee to forward a copy of the LIC 500 by close of business 09/23/2024. Licensee has been advised a meeting will be scheduled at the Orange County Regional office to discuss facility non-compliance. Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.the state’s words, verbatim · CDSS document, Sep 18, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Oct 3, 2024

All individuals subject to a criminal record review.. shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption.. This req is not being met as evidenced by: Based on interview and record review, Licensee failed to ensure two staff obtained criminal record clearance. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2024

Plan of correction: Licensee to obtain criminal record clearance and association for Staff 1 and 2 and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Oct 2, 2024

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This req is not being met as evidenced by: Based on observation, Licensee failed to ensure facility is clean, safe and sanitary. LPA observed a broken cupboard, buckling tile, and debris in yard. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2024

Plan of correction: Licensee to repair/ remove noted items and forward proof to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Caregiver Jesus Lopez. Administrator Jay Pichika arrive shortly after. According to the facility’s license, the facility has a maximum capacity of six residents, of whom all may be non-ambulatory, one of which may be bedridden. LPA toured the interior and exterior of the facility and inspected each room. There were multiple issues with the physical plant- room 6 walkway was semi-obstructed with construction tools, a large mirror and construction debris. Additionally there was a toilet in front of the closet which contained dark brown water. Double vanity outside room six is not in working condition, per residents has not worked in weeks. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Sink in double vanity was not draining water. Shower floors had dark mold and non-slip pads were slimy. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications labeled and locked as required. No pool or body of water was present. Water temperature was measured at 113 degrees F. Per Jay, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit was complete. Resident records reviewed did not contain Needs and Services Plans. Staff records reviewed did not have current first aid training in two of two records. Additionally, LPA informed Administrator of annual fees due to the Department. Multiple deficiencies were provided on todays date and one technical violation. An exit interview was conducted with Administrator, to whom a copy of this report,(LIC9099-x3), LIC9102, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jul 19, 2024

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.