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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607952
Report Date: 07/17/2024
Date Signed: 07/17/2024 01:19:59 PM


Document Has Been Signed on 07/17/2024 01:19 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:ROSE GARDEN VILLA IIFACILITY NUMBER:
197607952
ADMINISTRATOR:JUN FIGUEROAFACILITY TYPE:
740
ADDRESS:1151 MARCELLUS STREETTELEPHONE:
(562) 728-0916
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:6CENSUS: 4DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Administrator Jun FigueroaTIME COMPLETED:
01:45 PM
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On 07/17/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Jun Figueroa as the purpose of the visit was explained. The facility is licensed to serve (6) non-ambulatory residents ages 60 and above, there is an approved hospice waiver for (4). Current facility census is (4), facility fees are current. Liability insurance is active with an expiration date of 09/16/24.

The facility is a single-story structure located in a residential neighborhood and consists of the following; (4) resident bedrooms, (2) resident bathrooms, living room, dining room, family room, kitchen, office area, a laundry area, de- attached garage used for storage, and backyard with table and chairs. Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, showers was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to residents, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 2 staff records, 2 resident records, and 2 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 05/30/24, there is (1) fire extinguisher fully charged and located in the kitchen, carbon monoxide and smoke detectors were observed and are operational.

Exit interview conducted with Administrator Jun Figueroa, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
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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