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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801709
Report Date: 06/14/2023
Date Signed: 06/14/2023 03:19:48 PM

Document Has Been Signed on 06/14/2023 03:19 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: 27DATE:
06/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator / Zosimo PascasioTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced case management visit to this facility. Upon arriving at the facility, LPA met with Administrator / Zosimo Pascasio, who assisted with the visit. LPA explained the purpose of today’s visit is to follow up on the death of Client #1 (C1), which occurred on 5/16/23.

On 5/23/23, LPA Katrdzhyan conducted the initial visit to this facility and requested to review the file of C1. At the time of visit, the Administrator stated that the file was not available because the Temple City Sheriff's Department had confiscated the file of C1 and the file had not been returned back to the facility. LPA requested copies of the documents listed below to be faxed to CCL, by no later than 10am, on 5/24/23.

• Identification and Emergency Information • Physician's Report • Appraisal/Needs and Services Plan
• Admission Agreement • Temple City Sheriff's Report • Resident Appraisal • Medication Administration Record (MAR) • Consent Forms

LPA received copies of the Identification and Emergency Information, Admission Agreement, Consent for Medical Treatment, Mental & Physical Health Intake Assessment and Functional Capability Assessment. The forms were incomplete and missing the signature of C1 and/or C1's Responsible Party. The medical assessment for C1 was also missing.

The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
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 06/14/2023 03:19 PM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 06/14/2023 at 02:46 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: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
80070(a)

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Client Records. The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
This requirement is not met as evidenced by:
The Administrator submitted incomplete copies of the Identification and Emergency Information, Admission Agreement,
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The Administrator shall develop a written Plan of Correction (POC) to ensure compliance with California Code of Regulations Title 22, Section 80070. POC is due to CCL by the POC due date of 6/23/23.
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Consent for Medical Treatment, Mental & Physical Health Intake Assessment and Functional Capability Assessment for C1. The forms listed above were missing the signature of C1 and/or C1's Responsible Party. The medical assessment for C1 was also missing.
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


LIC809 (FAS) - (06/04)
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