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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609994
Report Date: 07/13/2020
Date Signed: 07/13/2020 05:09:36 PM

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 COLMANFACILITY NUMBER:
197609994
ADMINISTRATOR:HSU, MICHAELFACILITY TYPE:
740
ADDRESS:672 COLMAN STREETTELEPHONE:
(626) 375-8888
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:6CENSUS: 0DATE:
07/13/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Michael HsuTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Manya Lefian conducted an announced Pre-licensing visit to the facility and met with applicant Michael Hsu, LPA verified that applicant has completed component III on 02/21/2019 with LPA Joe Katrdzhyan from the Monterey Park Regional Office. The home capacity is for 6 individuals, 5 of which can be non-ambulatory. Fire clearance was granted on 01/02/2020.

LPA toured the inside and outside of the single family home, which includes six (6) bedrooms total for resident use. There are 3.5 bathrooms, a kitchen, dining room, living room and an activity sun room. There is a detached garage as well. LPA inspected facility for Fire safety, Personal Accommodations and Services, Medication Procedures, and Food Service.

There are adequate First-aid kits, linens, furnishings, perishable, nonperishable food and kitchen supplies. The appliances are clean and functional. The bathrooms have properly installed grab bars and skid mats. Hot water in bathrooms measured between 107.1 and 108.8 degree's Fahrenheit.

Facility alarm detectors are functional and the carbon monoxide detector also tested positively. Fire extinguisher is charged and serviced. There is a functioning telephone on the premises. There is a patio area, and table and chairs for resident use in the backyard. All medications, chemicals and sharps are in locked cabinets and drawers. There are no bodies of water on the premises.

Applicant will send LPA a copy of their liability insurance as soon as it is issued once license is granted.
Exit interview conducted and a copy of this report was issued
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Manya LefianTELEPHONE: (747) 230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2020
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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