197610160-1-29-2024-31-AS-GSAO-CZXUVL-20240129145518

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610160
Report Date: 01/29/2024
Date Signed: 01/29/2024 02:55:27 PM

Document Has Been Signed on 01/29/2024 02:55 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
WOODLAND HILLS S.RO, 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: 3	DATE:	01/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:52 PM
MET WITH:	Sandy Jeong		TIME COMPLETED:	03:30 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 01/29/24 at 12:50 PM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with Caregiver- and disclosed the purpose of the visit. The Administrator-Sandy Jeong was called and arrived at 1:25 PM.

LPA asked for the census, resident, and staff rosters.

A physical tour was conducted at 2:00 PM and observed the following:

The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The fire extinguisher is located against the wall on your left-hand side. It is fully charged with dated 05/2023. There is a telephone line on one of the counters in the kitchen. There is several extra pantries with canned food. The sharps are locked and inaccessible to the residents in one of the upper cabinets. The toxins are locked and inaccessible to the residents under the sink area.

There is one washer and dryer located next to the kitchen area locked and secured. There are chemicals in this area also locked and secured.

Outside/Backyard: The outside/backyard has furniture for residents with proper seating. The facility has a signal system. The facility has no pool or garage.

LIC 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: ROSE SENIOR CARE, INC. #2	FACILITY NUMBER: 197610160
	VISIT DATE: 01/29/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Bedrooms: There are four (4) bedrooms. One of the bedrooms is shared with a private bathroom. There are two (2) single, occupied rooms. There is a shared room that is vacant. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry and lightning. There are two (2) other bathrooms for resident and staff use. The bathrooms have proper toiletry and grab bars. The bathroom temperatures of the water are within regulations reading at 115–118-degree Fahrenheit. There are several cabinets that are filled with extra linen.

The dining area/living room area is located next to the kitchen where there is enough seating for the residents and the staff. There is a large television and there is also internet access. There is another area of the house which is for staff use where the files and medication are kept. The files and medication are locked and secured inaccessible to the residents. Next to the office area, there is extra seating for residents and/or staff. There is another phone line located in this area.

Administrative: There is no annual fee that is due right now. At the entrance of the facility there is COVID signs, Rights of Resident Roster, YES sign, Ombudsman, facility sketch, license certificate, personal rights, theft and loss policy. A copy of the mitigation plan was shown to the LPA for verification. The insurance plan dates 04/2023-04/2024.

The carbon monoxide and fire alarms are located throughout the facility and are operable and interconnected.

The faciltiy temperature is set at 73 degree Fahrenheit.

An exit interview was conducted, no citations were issued, and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2