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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801709
Report Date: 09/09/2021
Date Signed: 09/15/2021 09:49:57 AM

Document Has Been Signed on 09/15/2021 09:49 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ROSEMEAD VILLAFACILITY NUMBER:
197801709
ADMINISTRATOR:PASCASIO, ZOSIMOFACILITY TYPE:
735
ADDRESS:9025 GUESS STTELEPHONE:
(626) 280-4375
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 28CENSUS: 23DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Zosimo Pascasio, Administrator TIME COMPLETED:
04:03 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Zosimo Pascasio and explained the purpose of the visit. There are 23 ambulatory mentally disabled clients ages 59 and under. Facility has multiple single story detached buildings. It is located in a residential area consisting of 14 client rooms, 5 bathrooms, kitchen, dining room, laundry room, med-tech room, rear backyard, and a courtyard in the center of the property. The last fire drill was completed on Aug. 15, 2021. Administrator certificate expires 12/25/2022.

The following were observed/inspected:
  • COVID-19 Infection Control Practices were observed in common areas and all client rooms.
  • Infection control signs, and other signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Fourteen (14) client rooms, common areas, kitchens, bathrooms, and outdoor physical plant was inspected.
  • Seven (7) centrally stored 30-day client medication records were reviewed.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Clients were observed wearing masks and adhering to public health social distance guidelines.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed. PPE supplies were observed.
  • Pest control spray container was observed unlocked in the laundry room that is accessed by clients.
  • Cockroaches were observed on top of the kitchen counter.
  • Discarded mattresses, fencing, bed frames, drawer cabinets, and broken furniture was observed in the outdoor yard areas.


Deficiencies are cites according to Title 22. See 809D.
Exit interview was conducted with staff Zosimo Pascaiso. A copy of the report and appeal rights was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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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Document Has Been Signed on 09/15/2021 09:49 AM - It Cannot Be Edited


Created By: Noemi Galarza On 09/09/2021 at 03:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROSEMEAD VILLA
FACILITY NUMBER: 197801709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. At 1:15 pm a large pest control spray bottle was observed in the laundry room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2021
Plan of Correction
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Staff immediately stored the pest control spray bottle in a locked storage unit outside the laundry room.
DEFICIENCY IS CLEARED.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/15/2021 09:49 AM - It Cannot Be Edited


Created By: Noemi Galarza On 09/09/2021 at 03:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROSEMEAD VILLA
FACILITY NUMBER: 197801709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that discarded mattresses, fencing, bed frames, drawer cabinets, and broken furniture was observed in the outdoor yard areas which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2021
Plan of Correction
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Administrator agreed to remove all discarded items and will submit picture proof evidence by POC due date of 9/16/2021.
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that at 1:20 pm 7 cockroaches were observed on top of the kitchen counter which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2021
Plan of Correction
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Administrator agreed to submit proof of pest control company service order with an agreement of pest control services of a minimum of 4 weeks.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2021


LIC809 (FAS) - (06/04)
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