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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603417
Report Date: 06/15/2022
Date Signed: 06/15/2022 03:53:38 PM

Document Has Been Signed on 06/15/2022 03:53 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ROSANNA ADULT RESIDENTIAL HOMEFACILITY NUMBER:
197603417
ADMINISTRATOR:ROSANNA J. TOMANENGFACILITY TYPE:
735
ADDRESS:14605 HIAWATHA STREETTELEPHONE:
(818) 897-6964
CITY:MISSION HILLSSTATE: CAZIP CODE:
91345
CAPACITY: 6CENSUS: 4DATE:
06/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Rosanna TomanengTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Yelena Avetisyan conducted a Case Management visit to hand deliver an Immediate Exclusion Order of Staff #1 (S1) to the Licensee.

It was determined by the Department that a complaint of Conduct Inimical, Unusual punishment, Infliction of pain, mental abuse of R1 was substantiated against Staff #1, thus, necessitating the Order for Immediate Exclusion from all facilities. Staff #1 will also receive copies of the “Order To Licensee/Facility Of Immediate Exclusion From Facility” for the facilities with which Staff #1 is associated with..

The LPA hand delivered the "Order to Licensee/Facility of Immediate Exclusion from the Facility" in regards to Staff #1 to Administrator/Licensee Representative Rosanna Tomaneng. Licensee is the licensee for three of the facilities with which Staff #1 is associated: CCLE Home Care, LLC Facility # 197608120, Rosanna Adult Residential Home II Facility # 197605933. A copy of the "Order To Individual Of Immediate Exclusion From All Facilities” issued to Staff #1 was also provided. Administrator/Licensee Representative confirmed that Staff #1 has not worked at any of the Licensee's facilities Since August 2021.

Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2022
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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