<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801709
Report Date: 01/23/2024
Date Signed: 01/23/2024 02:31:09 PM


Document Has Been Signed on 01/23/2024 02:31 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: 27DATE:
01/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Zosimo, PacasioTIME COMPLETED:
02:46 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Alberto Lopez 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 Sunday 01/19/24.

On 01/23/2024, LPA Lopez conducted the initial visit to this facility and requested to review the file of C1.

LPA reviewed and obtained the following documents:

1) Identification and Emergency Information
2) Physician's Report
3) Appraisal/Needs and Services Plan
4) Admission Agreement
5) Temple City Sheriff's and LA County Coroner’s contact information.
6) Resident Appraisal
7) Medication Administration Record (MAR) for December and January 2024
8) Consent Forms

LPA requested copy of death certificate and coroners’ report when available.

LPA took a tour of facility and did not observe any health and safety hazards during the visit.

An exit interview was conducted, and a copy of this report was provided to the Administrator along with the Appeals Rights.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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 1