197610160-9-13-2022-31-AS-JMAZ-CJ8V29-20220913160247

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610160
Report Date: 09/13/2022
Date Signed: 09/13/2022 04:03:32 PM

Document Has Been Signed on 09/13/2022 04:03 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. #2		FACILITY NUMBER:	197610160
ADMINISTRATOR:	JEONG, SANDY		FACILITY TYPE:	740
ADDRESS:	17611 TUBA STREET		TELEPHONE:	(818) 217-4955
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY: 6		CENSUS: 4	DATE:	09/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Sandy Jeong		TIME COMPLETED:	04:10 PM

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On 09/13/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA met Administrator Sandy Jeong. The purpose of the visit was explained. Entrance interview conducted.

A physical plant tour was conducted at 2:40 p.m and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Administrator screened LPA for covid symptoms and took LPA’s temperature. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Smoke detectors/carbon monoxide are located throughout the facility and are dual hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 3:18 p.m. and appear to be functional. Facility has a fire door that was operational when the fire alarms were tested. Fire extinguisher has a purchase date of 04/04/2022. Common Areas: All common areas were observed to be clean and properly furnished. Facility’s temperature at the time of the visit was 76 F. Facility has a designated laundry room that is kept locked and inaccessible to residents in care. Medication are centrally stored in a locked cabinet in the office area. Resident Rooms: Facility has four (4) bedrooms designated for resident use. Two bedrooms are shared, and two bedrooms are for single use. All (4) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting and furniture. Bathrooms: There are three (3) bathrooms in the facility of which two (2) are designated for resident’s use. LPA observed all bathrooms to be cleaned. The hot water was tested and measured 116.9 F, which is in regulation. All trash cans located in the bathrooms had tight fitting lids. Grab bars and non-skid were observed (Continue on 809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

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. #2	FACILITY NUMBER: 197610160
	VISIT DATE: 09/13/2022

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Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. There is a shack located outside that is used for additional storage. There are no bodies of water. The facility has an attached ADU that is not part of the licensed facility and is inaccessible to residents.

No deficiencies cited. Exit interview conducted. Report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

LIC809 (FAS) - (06/04)

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