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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801709
Report Date: 08/31/2023
Date Signed: 08/31/2023 01:43:38 PM

Document Has Been Signed on 08/31/2023 01:43 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
GREATER LA AC/SC, 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: 25DATE:
08/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Caren Tamalega - Staff TIME COMPLETED:
02:05 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores and Nune Margaryan conducted an unannounced annual visit at the facility using the CARE tool. LPAs met with Caren Tamalega staff and explained the reason for the visit. Admininstrator arrived 30 minutes later.

Facilty is licensed to served 28 adults between the ages of 18-59 years old. Facility has multiple single story detached buildings. It is located in a residential area consisting of 14 client rooms, 4 bathrooms, 1 staff bathroom, kitchen, dining room, laundry room, med-tech room, rear backyard, and a courtyard in the center of the property.

LPAs conducted a tour of the facility with Caren Tamalega staff and observed the following: Room
Four (4) Client rooms were observed, each room has the required furniture/bedding, and sufficient lighting. Room #14 a chest drawer was observed with the last drawer broken. Four (4) bathrooms were observed in working condition, each had spider webs and spiders in the corners of the ceiling. Water temperature was tested in each bathroom and tested between 116.2-150.9 degrees F., which is not within the required 105-120 degrees F. Kitchen was observed clean, cleaning supplies were locked in a cabinet, knives were locked in a drawer. Refrigerator was observed to have an unlock drawer with medication that needs to be refrigerated. Storage room had additional refrigerators and freezers, thermometers were not observed in any of the refrigerators or freezers. Roaches were observed crawling out of the refrigerator located in the storage. Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Dining room was observed clean. Activity/TV room was observed dusty, with boxes against the wall, furniture in between furniture, crates set up as a table, and bug spray inside an unlock furniture cabinet. Outdoor area was observed with sufficient shading sitting area. A chair outside room #14 was observed ripped, and vomit or food waste was observed in the grass in front of the office area.
(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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 9
Document Has Been Signed on 08/31/2023 01:43 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/31/2023 at 12:04 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: 08/31/2023

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 in bottle of bug spray was observed in a cabinet in the activity/TV room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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Administrator will cerity in LIC 9098 that will ensure all chemicals are lock at all times and will schedule staff training regarding section 80087 and will submit to the department by POC due date 9/1/23. Training log, topic, duration of training will be submitted to the department by 9/7/23.
Type A
Section Cited
CCR
80087(h)
Building and Grounds
(h) Medicines shall be stored as specified in Section 80075(m) and (n) and separately from other items specified in Section 80087(g) above.

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 medication in need of refrigeration was observed in an unlock drawer in kitchen's refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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Administrator will purchase a box with lock to keep in the refrigerator and will submit picture to the department by POC due date 8/31/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 08/31/2023 01:43 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/31/2023 at 12:04 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: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 water temperature was tested in bathroom #2 (Men's Building between Room #3-#5) at 150.9 degrees F., Bathroom #3 (B3) (Women's Builiding next to room #9) at 123.9 degrees F., Sink outside B3 tested at 122.1 degrees F., Bathroom #4 (Room #12) at 125.4 degrees F.,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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Administrator will adjust water temperature to ensure is between 105-120 degrees F,, will ceritfy in LIC 9098 will submit to the department by POC due date 9/1/23. Administrator will keep a log for 7 days for each bathroom and will submit the log by 9/7/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 08/31/2023 01:43 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/31/2023 at 12:04 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: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

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 an infection control plan was not available for review and a copy has not been submitted to the department which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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Licensee will provide a copy of Infection Control Plan by POC due date 9/7/23.
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 vomit or food waste was observed in front of the office in the grass area, a chair was observed ripped, and TV room was observed with furiniture on top of furniture, crates were used as a table, Room #14 has a chest drawer with a broken drawer which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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Administrator will clear, clean, organize, and provide proper furniture in TV/activity room, clean vomit/food waste in grass area, will replace or discard of ripped chair(s), and replace chest drawer, and will submit picutres to the department by POC due date 9/7/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 08/31/2023 01:43 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/31/2023 at 12:04 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: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 spiders/spider webs were observed in bathroom's corners, a roach was observed crawling in storage refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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Administrator will contact pest control service company, provide proper pest services, and clean webs around the facility. Administrator will submit invoices of pest control services provided and pictures of the clean areas to the department by POC due date 9/7/23.
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

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 current HIV/TB training was not observed or available at the time of the visit for administrator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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Administrator will provide a copy of current HIV/TB training by POC due date 9/7/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 08/31/2023 01:43 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/31/2023 at 12:04 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: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 administrator's first aid certificate expired 7/14/23 and no other staff had first aid training on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2023
Plan of Correction
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Adminiistrator will submit a copy of currnet first aid training for each staff member by POC due date 9/14/23.
Type B
Section Cited
CCR
85076(d)(2)
Food Service
(2) Freezers shall be large enough to accommodate required perishables and shall be maintained at a temperature of zero degrees F (-17.7 degrees C).

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 freezer in kitchen, 3 freezers in storage room did not have thermometers to check temperature which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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Administrator will provide thermometers in each freezer and ensure temperature is at zero degrees F, will submit a picture of 4 freezers with thermometer at the correct temperature to the department by POC due date 9/7/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 08/31/2023 01:43 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/31/2023 at 12:04 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: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(3)
Food Service
(3) Refrigerators shall be large enough to accommodate required perishables and shall maintain a maximum temperature of 45 degrees F (7.2 degrees C).

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 refrigerator in kitchen, 2 refrigerators in storage room did not have thermometers and temperature was not available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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Administrator will provide thermometers in each refrigerator and ensure temperature is at maximum of 45 degrees F, will submit a picture of 3 refrigerators with thermometer at the correct temperature to the department by POC due date 9/7/23.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 Emergency and Disaster plan provided for review dated 8/31/23 is LIC 610D version (5/01) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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Administrator will submit LIC 610D (12/21) to the department by POC due date 9/7/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 08/31/2023 01:43 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/31/2023 at 12:04 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: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(e)
Other Provisions
(e) A facility shall have all of the following information readily available during an emergency:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in facility does not have a binder or plan with the required; face sheet, assessment, and medication sheets readily available for an emergency which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2023
Plan of Correction
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Administrator will provide a picture of readiliy availalbe binder which includes; face sheet, needs and care plan, medication sheet for all clients in care to the department by POC due date 9/14/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
Page: 8 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/31/2023
NARRATIVE
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Smoke/Carbon Monoxide detectors were tested and in working condition. Fire Sprinkle system was noted on the front buildings and last Fire Department inspection was conducted on 9/1/22. Fire Extinguishers were lasted checked on 8/15/23.

LPAs reviewed medication, P&I money, and files for 5 clients, and 5 staff files. Administrator was not able to provide a copy of HIV/TB training, administrator's last First aid training expired on 7/14/23, no other staff had a CPR training on file. Infection Control Plan was not available for review at the time of the visit and Disaster Plan provided was version (5/01) which is not the most current version.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Zomiso Pasciaso Administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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