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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602038
Report Date: 04/29/2021
Date Signed: 04/29/2021 03:15:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:FLOWERS RESIDENTIAL CARE FACILITYFACILITY NUMBER:
197602038
ADMINISTRATOR:SARAH KIRKFACILITY TYPE:
740
ADDRESS:2762 VISSCHER PLACETELEPHONE:
(626) 797-7996
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:6CENSUS: 4DATE:
04/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Roderick Kirk, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Rosaura Valenzuela and Naira Margaryan conducted an unannounced
LPAs informed the Administrator that this visit was a follow up with the Department’s request to submit a mitigation plan and to ensure that the facility is continuing to operate.
Between February 20201 and April 2021 LPA Valenzuela made several attempts to speak with the Administrator to request the copy of mitigation plan. However, the attempts were unsuccessful, and the facility phone number was disconnected, or no one responded to the calls.
At the time of this visit at 2:10pm LPAs Valenzuela and Margaryan informed the Administrator that on 02/22/2021, LPA Valenzuela spoke with the administrator Roderick Kirk and Advised Mr. Kirk that their mitigation plan is past due. LPA Valenzuela requested Mr. Kirk is to submit the mitigation plan by 5pm on 2/24/21 to CCLASCPWoodlandHillRO@dss.ca.gov. Pin 20-48-ASC, PIN 21-01-ASC and a copy of the LIC 808 – documentation regarding a mitigation Plan) was shared with Mr. Kirk vial e-mail. Up to date no respond was received to the request.
The administrator verified that he did not complete the mitigation plan and that facility phone was not working for three days.

LPAs informed the administrator that at the time of this visit the facility will be cited due to noncompliance of the Licensing Requirements; Not submitting Mitigation Plan in timely fashion as it was requested by Licensing Office and not having operable telephone service on premises. During this visit, LPAs checked telephone line and it was working.
Under Title 22, Division 6; Chapter 8 following citation was issued and recorded on LIC809D. Exit interview is conducted and a copy of report was issued,
case management to the facility and met with Roderick Kirk, administrator
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FLOWERS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197602038
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/03/2021
Section Cited

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87211(a) Reporting Requirements-(a) Each licensee shall furnish to the licensing agency such reports as the Department my require.
This requirement was not met as evidenced by: Facility did not submit mitigation plan to the Department before the due date.
This poses an immediate health and safety risk to residents in care.
Type B
04/29/2021
Section Cited

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87311 Telephones;
All facilities shall have telephone service on the premises.
This requirement was not met as evidenced by:
The phone was not working for three days.

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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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2021
LIC809 (FAS) - (06/04)
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