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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609538
Report Date: 04/08/2022
Date Signed: 04/08/2022 04:04:35 PM


Document Has Been Signed on 04/08/2022 04:04 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:ROSE VALLEY ALTADENA IFACILITY NUMBER:
197609538
ADMINISTRATOR:HSU, MICHAELFACILITY TYPE:
740
ADDRESS:2135 SANTA ANITA AVETELEPHONE:
(626) 375-8888
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:6CENSUS: 0DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Monica AguileraTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with the administrator, Monica Aguilera, for a One (1) Year Required - Infection Control visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 12:45pm and the following was noted:

There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs are posted outside. Hand washing, coughing etiquette, physical distancing and other necessary signs are posted in the bathroom and throughout the facility. The facility has a total of four (04) bedrooms and two (02) bathrooms for both residents and staff. Currently, the facility is not occupying residents. The facility has outdoor furniture with a covered shaded area for potential residents and visitors and does not have a swimming pool/body of water. No laundry detergents, cleaning agents and other toxins on the premise. Kitchen is in working order but there is no food as the facility is not occupying residents. Knives and sharps are observed to be locked and inaccessible to potential residents. The living and dining room are currently empty as they are renovating certain areas of the facility. The facility maintains a comfortable temperature at 74°F. The smoke and carbon monoxide detectors are hardwired and observed to be operational. The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. The bathrooms were checked for proper operations. The hot water temperature was measured at 110°F.
Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
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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