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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609540
Report Date: 06/02/2025
Date Signed: 06/02/2025 04:27:10 PM

Document Has Been Signed on 06/02/2025 04:27 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ROSE VALLEY ALTADENA IIFACILITY NUMBER:
197609540
ADMINISTRATOR/
DIRECTOR:		HSU, MICHAELFACILITY TYPE:
740
ADDRESS:2137 SANTA ANITA AVETELEPHONE:
(626) 765-6181
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 6CENSUS: 6DATE:
06/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Monica Aguilera, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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At 10:15a.m., Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced Required One (1) year inspection to the facility. LPA met with caregivers that granted entry to the facility and explained the reason for the visit. Later, Administrator joined today’s visit.

At 10:45a.m., LPA and administrator conducted a physical plant tour inside and out. During the tour, LPA observed that the facility is a home located in a residential community. Required postings were observed in the entry area. The smoke alarms are operational, they are in each bedroom and hallways. There are carbon monoxide detectors that function properly. The fire extinguishers are located throughout the facility. The charge date is 02/14/2025. Fire/Earthquake emergency drill was last conducted on 05/14/2025. During this visit the facility is at 70 degrees Fahrenheit. The facility is fire cleared for six (6) non-ambulatory residents; two (2) hospice waiver.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Kitchen: LPA observed kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. The menu was posted for review, snacks and beverages are available for the resident in the facility when they want. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the kitchen under the sink.

Cont. LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROSE VALLEY ALTADENA II
FACILITY NUMBER: 197609540
VISIT DATE: 06/02/2025
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Cont. LIC 809

Bedrooms: LPA observed seven (7) bedrooms designated for residents use. Bedroom #6 is vacant. All bedrooms were toured and observed to be clean and properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Bathrooms: LPA observed the bathrooms to be clean, sanitary and with necessary supplies. The appropriate grab bars and mats in the shower. Hot water temperature measured at a range of 109.9°F to 119.0°F and within the required range. Resident’s personal hygiene supplied are kept separate in clear plastic containers stored in a locked cabinet under the sink. Towels and washcloths are not shared. Common Areas: These included the living room and dining area for residents. The common areas were properly furnished. Furniture in common area was observed to be in good repair. Residents dining table fits six (06) residents. No obstructions and or tripping hazards throughout the facility. There are no issues with Fire Clearance. Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. The facility does not have a garage, just a car port. Laundry Room: LPA observed washers and dryers machines l located between rooms #6 & #7 and inaccessible to residents in care. Linen are also storage in laundry room and observed to have ample supply of clean linen, comforters, and towels in facility. Cleaning supplies are being also stored in locked cabinets in the laundry room. Medications are in a centrally stored and locked medication closet, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the resident’s doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and were observed to be stored in medication closet. Staff Files: LPA conducted a file review of staff files for criminal record clearances and current First Aid. All four (4) staff files reviewed were current at the time of this visit. Resident Records. LPA conducted a resident record review for six (06) residents for requirements and legibility. All residents records were current at the time of this visit. Resident were also interviewed.

Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report has been issued and discussed.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025
LIC809 (FAS) - (06/04)
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