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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609753
Report Date: 06/03/2024
Date Signed: 06/04/2024 08:25:59 AM


Document Has Been Signed on 06/04/2024 08:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:ROSE SENIOR CARE INCFACILITY NUMBER:
197609753
ADMINISTRATOR:JEONG, SANDYFACILITY TYPE:
740
ADDRESS:18406 BLACKHAWK STTELEPHONE:
(818) 217-4955
CITY:PORTER RANCHSTATE: CAZIP CODE:
91326
CAPACITY:6CENSUS: 6DATE:
06/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sandy Jeong- AdministratorTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff, and explained the reason for the visit. Administrator had arrived shortly after.
At approximately 10:15 am, with the assistance of the Administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are hardwired and operated. There is a carbon monoxide detector that functions properly installed in the hallway between resident rooms. The fire extinguisher is located by the kitchen. LPA was informed that annual service for the fire extinguisher is scheduled on June 11, 2024. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the office cabinets.
Bedrooms: There were four(4) bedrooms designated for residents' use. Two (2) bedrooms are designated for private use, and two (2) rooms are shared. All four bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting.
Bathrooms: The facility has four (4) bathrooms. Three (3) bathrooms designated for residents' use and one(1) bathroom designated for staff. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 115.6 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection.
Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. LPA observed a small golf court and turtle pet house in the backyard for the residents. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.Medications: Medication and Medication Records were review for proper documentation.Temperature: Facility maintains a comfortable temperature of 78 degrees Fahrenheit

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024
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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