<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603417
Report Date: 09/20/2021
Date Signed: 09/20/2021 05:19:42 PM

Document Has Been Signed on 09/20/2021 05:19 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: 5DATE:
09/20/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:25 PM
MET WITH:Rosanna TomanengTIME COMPLETED:
05:30 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
An unannounced case management visit was conducted on this day by licensing program analyst (LPA) Yelena Avetisyan.

The purpose of this visit is to issued amendment of the original complaint reports which were issued on 08/24/2021 for complaint control # 31-AS-20210818093758.

During the 8/24/2021 visit approximately 8:20 am while conducting interview with the licensee/administrator Rosanna Tomaneng LPA discovered that Staff 1 (S1's) criminal record clearance was not transferred to this facility and Staff 2 (S2's) criminal record clearance was Inactive and the staff required a criminal record exemption prior to working and/or having any contact with clients in care. Additionally LPA reviewed the criminal record clearance roster that was reviewed, signed by Ms. Tomaneng and returned to the Woodland Hills South Regional Office. S1 and S2 were not listed on the roster. A discussion was held with Ms. Tomaneng regarding Criminal Record Clearance requirements. Due to time constraints LPA was unable to issue the deficiencies during the 8/24/2021 visit.


Exit interview conducted and copy of the amended report as well as this report, citations, civil penalties were emailed to Rosanna Tomaneng.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/20/2021 05:19 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 09/18/2021 at 09:32 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSANNA ADULT RESIDENTIAL HOME
FACILITY NUMBER: 197603417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2021
Section Cited
CCR
87355(e)(1)

1
2
3
4
5
6
7
87355(e)(1) Criminal Record Clearance. (e) ...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator contacted the 1 on 1 caregiver and requested that she not report to work until she receives her criminal record clearance and approved exemption as necessary.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above as S2 worked as a caregiver/1 on 1 staff at the facility without a criminal record clearance and exemption, which posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
This is a zero tolerance violation, therefore civil penalties in the amount of $500 is being issued.

Deficiency cleared during the visit.
Deficiency Dismissed
Type A
09/19/2021
Section Cited
CCR87355(e)(2)

1
2
3
4
5
6
7
87355(e)(2) Criminal Record Clearance. All individuals subject to a criminal record ... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
During the visit Ms. Tomaneng agreed that staff 2 will not work at the facility until her criminal record clearance transfer is completed. 8/27/2021 Licensee/administrator submitted documents to transfer the criminal records clearance for staff to this facility.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above as S1 worked as a caregiver at the facility without arequesting and confirming transfer of criminal record clearance which posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
This is a zero tolerance violation, therefore civil penalties in the amount of $500 is being issued.

Deficiency cleared during the visit.
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:Eva Miller
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2