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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608981
Report Date: 09/13/2021
Date Signed: 09/13/2021 04:22:44 PM

Document Has Been Signed on 09/13/2021 04:22 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ROSEWOOD ASSISTED LIVING FACILITYFACILITY NUMBER:
197608981
ADMINISTRATOR:FACILITY TYPE:
735
ADDRESS:433 NORTH KENMORE AVENUETELEPHONE:
(323) 863-6563
CITY:LOS ANGELESSTATE: CAZIP CODE:
90004
CAPACITY: 34CENSUS: 33DATE:
09/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Shahbaz BaigTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Shahbaz Baig and explained the purpose of today's visit.

This is an ARF with a capacity of 34. The facility is licensed to serve 34 ambulatory clients. All ambulatory clients. The following was inspected and toured: The facility consists of 17 Client bedrooms (all shared), 2 Staff bedrooms, 5 client bathrooms, 1 staff bathroom, kitchen, dining area and common area for clients.

The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms and hallways.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Clients are able to use a designated isolation room that will be used as isolation rooms if a COVID-19 positive case should arise.
  • 30 day supply of medication reviewed for (9) residents (Client #1 through Client #5)
  • Facility has an adequate amount of PPE and facility has enough PPE for 6 months.
  • Clients were socially distanced according to local public health guidelines.
  • Clients were wearing masks.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed (including paper goods, utensils etc).
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ROSEWOOD ASSISTED LIVING FACILITY
FACILITY NUMBER: 197608981
VISIT DATE: 09/13/2021
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According to the California Code of Regulations, LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Administrator Shahbaz Baig and copy of report provided.

SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC809 (FAS) - (06/04)
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