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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801709
Report Date: 01/13/2025
Date Signed: 01/13/2025 04:06:36 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/16/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241216124434
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:
01/13/2025
UNANNOUNCEDTIME BEGAN:
01:59 PM
MET WITH:Evelyn Dela Cruz, DSP TIME COMPLETED:
04:16 PM
ALLEGATION(S):
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Staff does not prevent bed bug infestation.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez made subsequent visit to continue investigation and deliver findings for the alleged allegations above. LPA met with Evelyn Dela Cruz (DSP) and discussed the purpose of the visit.

2/23/2024 The investigation consisted of: LPA obtained a copy of the Client Roster and Staff Roster. LPA interviewed five (5) staff (S#1-S#5) and six (6) clients (C#1-C#6). Additional interviews need to be conducted prior to completing investigation. LPA will return on later date to complete.

During todays visit, LPA interviewed two (2) more staff (S#6-S#7) and took tour of facility.

The investigation revealed; Allegation: Staff does not prevent bed bug infestation. It is alleged that facility has bed bug infestation.
(continued on 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20241216124434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ROSEMEAD VILLA
FACILITY NUMBER: 197801709
VISIT DATE: 01/13/2025
NARRATIVE
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(Continued from 9099)
LPA took a tour of facility rooms and interviewed total of seven (7) staff. Four (4) of seven (7) staff acknowledged the bed bugs. S2 stated S2 observed 4 bud bug eggs in room #6 on 12/23/2024. S2 stated that they spray the area where there are bed bugs and wash the linens right away. S1 stated they have not called exterminator due to cost. LPA interviewed six (6) clients and three (3) of (6) clients were able to corroborate the allegation. There is enough evidence to support this allegation.

Based on LPA interviews which were conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D.

Exit interview conducted with Evelyn Dela Cruz (DSP) and copy of report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20241216124434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROSEMEAD VILLA
FACILITY NUMBER: 197801709
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2025
Section Cited
CCR
80087(a)(1)
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80087(a)(1) 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 the 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 evidenced by:
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The Administrator shall submit a plan of correction by the due date. The plan will include professional extermination services to eradicate the bedbug issue.
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S2 stated S2 observed 4 bed bug eggs in client's room on 12/23/2024 and that S2 sprays and washes linens when S2 observes evidence of bed bugs while cleaning the rooms.
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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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/16/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241216124434

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:
01/13/2025
UNANNOUNCEDTIME BEGAN:
01:59 PM
MET WITH:Evelyn Dela Cruz, DSP TIME COMPLETED:
04:16 PM
ALLEGATION(S):
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Staff does not provide a comfortable room temperature for residents.
Staff yelled at resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez made subsequent visit to continue investigation and deliver findings for the alleged allegations above. LPA met with Evelyn DeLa Cruz (DSP) and discussed the purpose of the visit.

12/23/2024 The investigation consisted of: LPA obtained a copy of the Client Roster and Staff Roster. LPA interviewed five (5) staff (S#1-S#5) and six (6) clients (C#1-C#6). Additional interviews need to be conducted prior to completing investigation. LPA will return on later date to complete.

During todays visit, LPA interviewed two (2) more staff (S#6-S#7) and took tour of facility.

The investigation revealed, Allegation: Staff does not provide a comfortable room temperature for clients. It is alleged that the heater is not working and some clients rooms are very cold at night.
(continued on (9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20241216124434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ROSEMEAD VILLA
FACILITY NUMBER: 197801709
VISIT DATE: 01/13/2025
NARRATIVE
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(continued from 9099)
LPA interviewed total of seven (7) staff and seven (7) of seven (7) staff denied the allegation. S1 stated that the heater was repaired as soon as they were aware of the issue and provided LPA with invoice dated 12/12/2024 from GR Plumbing and Heating. LPA interviewed six (6) clients and three (3) of six (6) clients could not corroborate the allegation. Facility has addressed this issue and LPA asked S1 to have plumbing company return to make sure repairs are holding up.

Allegation: Staff yelled at client. It is alleged that S7 yelled at client. LPA interviewed seven (7) staff and seven (7) of seven (7) staff denied the allegation. S7 denied yelling at client and stated client was the one yelling. LPA interviewed six (6) clients and five (5) of six (6) clients were not able to corroborate the allegation. There is not enough evidence to support this allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated



Exit interview was conducted. Copy of report provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5