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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801709
Report Date: 12/23/2024
Date Signed: 12/23/2024 12:25:51 PM

Document Has Been Signed on 12/23/2024 12:25 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/
DIRECTOR:		PASCASIO, ZOSIMOFACILITY TYPE:
735
ADDRESS:9025 GUESS STTELEPHONE:
(626) 280-4375
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 28CENSUS: 26DATE:
12/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:48 AM
MET WITH:Zosimo Pacasio, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:28 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced case management visit. LPA met with Marilu A Pagadora, Direct Support Staff for the facility, and explained the purpose of the visit. Zosimo Pacasio, Administrator, arrived shortly thereafter. The visit was conducted in response to the death of Client #1 (C1), who passed away on 12/17/2024

During the visit, LPA interviewed the administrator Zosimo Pacasio and also obtained C1's Physician's Report, FACE Sheet, Appraisal/Needs and Services Plan, and C1 Medication Administration. LPA requested a copy C1's death certificate once it becomes available. LPA also toured the bedroom of C1 and found no concerns.

The death has been determined to not be suspicious.

At this time, no further action is required, and no citations will be issued. Exit interview held and a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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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