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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609994
Report Date: 07/14/2021
Date Signed: 07/14/2021 01:47:30 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:
07/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Michael Hsu, LicenseeTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required One (1) year-Infection Control inspection to the facility. LPA met with Michael Hsu, Licensee and explained the reason for the visit.

A tour of the physical plant was conducted at 11:55am and the following was noted:

There is only one entrance being utilized at the facility.

The facility had submitted and approved Mitigation Plan.

The facility has six (6) bedrooms and three (3) bathrooms currently occupying zero (0) residents. All six (6) bedrooms are private rooms.

Currently the facility does not have any residents in care. LPA inspected all rooms and they are empty. The refrigerator does not have any food inside.

(continued on LIC 809-C
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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 VALLEY COLMAN
FACILITY NUMBER: 197609994
VISIT DATE: 07/14/2021
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Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 76 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide detector in the facility. Fire extinguisher is located adjacent to the kitchen.

The right side of the facility has a sun room with furniture. There is no body of water at the facility.

Laundry area is located inside the kitchen.

The residents rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passage ways are lit.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the shower and toilet. The hot water temperature was measured at 119.9 degrees. There was enough clean linen available inside the closets.

There was one ( 1) complete first aid kit located inside one of the closets.

Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC809 (FAS) - (06/04)
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