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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801709
Report Date: 08/30/2022
Date Signed: 08/30/2022 01:38:43 PM

Document Has Been Signed on 08/30/2022 01:38 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, 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: 26DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Zosimo Pascasio, LicenseeTIME COMPLETED:
01:45 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 26 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.

***Major deferred maintenance throughout the facility was observed.
  • No COVID-19 visitor screening is in place. 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. Rooms 1 and 3 had dirty bed linens. Room 1's bed was missing sheets.
  • All client rooms had dirty flooring, Rm 11 had very dirty bathroom shower tiles/moldy shower curtain, Rm 7 had extremely dirty & broken blinds, and there was discarded furniture debris throughout the facility. Two (2) outdoor benches, and broken bedroom dressers were observed. The laundry room/pantry room had unlocked paint thinner, paint, and detergent.
  • Nine (9) centrally stored 30-day client medication records were reviewed.
  • No staff or clients were observed wearing masks.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed. However, spoiled vegetables, damaged canned goods, and expired bottled sauces were observed.
  • A posted Emergency Disaster Plan was observed. PPE supplies were observed.
  • The facility has not conducted a fire and earthquake drill since Aug. 15, 2021, over 1 year ago. LPA called LA County Fire Department to confirm the date of the last inspection. Due to COVID-19 pandemic the Fire Department has a backlog of facility inspections.

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: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2022
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 6
Document Has Been Signed on 08/30/2022 01:38 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/30/2022 at 12:34 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: 08/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1550(c)
Suspension and Revocation
(c) Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home.

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 there is no visitor screening in place and LPA was not screened upon entry into the facility; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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Licensee/Administrator shall submit a written plan of how the deficiency was corrected. POC is due tomorrow.
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 laundry room/pantry room had unlocked paint thinner, paint, and detergent; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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Licensee/Administrator shall submit a written plan of how the deficiency was corrected. Send picture proof evidence that the dangerous products were locked. POC is due tomorrow.
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: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/30/2022 01:38 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/30/2022 at 12:34 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: 08/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

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 multiple cauliflowers and cabbage were spoiled, 2 expired Alfredo sauce jars, and one damaged canned container was observed in the pantry; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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Licensee/Administrator shall submit a written plan stating what was done to correct the deficiency. In addition, all staff shall receive training regarding 80076. POC is due tomorrow.
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: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/30/2022 01:38 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/30/2022 at 12:34 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: 08/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Buildings 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 facility has major deferred maintenance. All client rooms had dirty flooring, broken dresser drawers, Rm 7 had extremely dirty & broken blinds, and there was discarded furniture debris throughout the facility. Two (2) outdoor benches, and broken bedroom dressers were observed; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2022
Plan of Correction
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Licensee/Administrator shall fix all deferred maintenance, replace broken dresser drawers, ensure that all client rooms are kept in clean, safe, and sanitary conditions at all times, and shall discard and replace broken benches/seating in the outdoor patio areas.
Section Cited
Building and Grounds
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: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/30/2022 01:38 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/30/2022 at 12:34 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: 08/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

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 all facility bathrooms have poor maintenance, dirty shower tiles and floors; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2022
Plan of Correction
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Licensee/Administrator shall submit picture proof that all bathroom shower tilesm and all client rooms were deep cleaned. If necessary hire a professional cleaning service and submit a copy of the invoice.
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

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 rooms 1 and 3 had dirty bed linens. Room 1's bed was missing sheets; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2022
Plan of Correction
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Licensee/Administrator shall: 1. Ensure all client beds have clean linens at all times 2. conduct staff training 3. Submit a written plan stating what was completed in order to rectify the deficiency.
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: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/30/2022 01:38 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/30/2022 at 12:34 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: 08/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the facility has not conducted a fire and earthquake drill since Aug. 15, 2021, over 1 year ago; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2022
Plan of Correction
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Licensee/Administrator shall conduct a fire and earthquake drills shall be conducted at least once every three months, and maintain a record of the drills. Submit a copy of the drill.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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3
4
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: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022


LIC809 (FAS) - (06/04)
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