197609753-4-5-2022-31-AS-TSMH-CD7UDN-20220405152948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609753
Report Date: 04/05/2022
Date Signed: 04/05/2022 03:29:56 PM

Document Has Been Signed on 04/05/2022 03:29 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 SENIOR CARE INC		FACILITY NUMBER:	197609753
ADMINISTRATOR:	JEONG, SANDY		FACILITY TYPE:	740
ADDRESS:	18406 BLACKHAWK ST		TELEPHONE:	(818) 217-4955
CITY:	PORTER RANCH	STATE: CA	ZIP CODE:	91326
CAPACITY:	6	CENSUS: 5	DATE:	04/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	SANDY JEONG		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an unannounced annual/infection visit to this facility. LPA was greeted by facility staff Allan Shin, who was observed wearing a mask. LPA temperature taken upon entry. LPA informed staff the purpose of this visit. The administrator was called at 10:10 AM and arrived later.

LPA reviewed files for all residents and staff between 11:20 am-1:15 pm. Resident files included current medical assessments, physician orders for medications and centrally stored medication logs. Medications are given as prescribed. LPA reviewed files for staff at the facility. Staff files included current first aid and CPR certifications as well as sufficient training documentation. All staff have criminal record clearance and all are associated to this facility.

LPA conducted a tour of the physical plant between 12:55-1:40 PM to ensure there are no health and safety hazards and facility is following Title 22 Regulations.

The living area had furnishings and sufficient lighting and observed adequate seating for residents. Smoke alarms and carbon monoxide detectors were present and function properly. Fire extinguisher serviced 04/04/2022.

There were (4) four bedrooms designated for residents' use. All bedrooms were clean, properly furnished and had sufficient lighting. Extra linen stored for each resident in own room. There were three (3) bathrooms designated for residents' use. All bathrooms were clean, properly supplied and had functional fixtures. The water temperature range was between 105.0- and 120.0-degrees Fahrenheit.

Dining area: Sufficiently lighting and furnishings. LPA observed adequate seating for residents:(1) one small round table with seating for (4) four and (1) one large rectangular table with seating for (6) six. LPA observed to the left of the dining area a staff lounge room no live-ins.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE SENIOR CARE INC	FACILITY NUMBER: 197609753
	VISIT DATE: 04/05/2022

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(Cont from 809)

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the five (5) clients currently residing there. Two (2) days of perishable fruits, vegetables, milk and eggs observed. The freezer is stocked with meats and poultry with a second refrigerator in the garage. The sharps are locked under kitchen bar counter. First aid kit stored in upper kitchen cabinet to the right of the sink. Cleaning supplies locked under kitchen sink cabinet with additional supplies locked in garage,

The medications are locked in cabinet in administrator office area. A backup first aid kit also stored in medication cabinet.

There is a supply of canned foods, dried foods, and extra paper towels and water in the garage including a sufficient supply of PPEs.

The grounds entry/exits, and patio area were clean and free of obstruction.

There are no deficiencies to report. Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC809 (FAS) - (06/04)

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