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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801709
Report Date: 03/01/2024
Date Signed: 03/01/2024 12:15:00 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
02/13/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240213092126
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:
03/01/2024
UNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Zosimo PacasioTIME COMPLETED:
12:22 PM
ALLEGATION(S):
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Staff does not provide a clean and sanitary environment for residents in care.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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LPA made subsequent visit to deliver findings for the complaint investigation. LPA met with Administrator Zosimo Pacasio and discussed the purpose of the visit.

On previous visit on 02/15/2024 LPA interviewed 4 staff S#1 - S#4, 6 Clients C#1 - C#6 .and 1 witness W1.
LPA reviewed and obtained Staff and client rosters and blank admission agreement. LPA tour the facility common areas, kitchen, 5 bathrooms, and 14 client rooms.

The investigation revealed:

Allegation: Staff does not provide a clean and sanitary environment for residents in care. It is alleged that some resident rooms and linens are uncleaned.

(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: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
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-20240213092126
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: 03/01/2024
NARRATIVE
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Licensee(S1) stated that rooms are cleaned daily. S3 (Maintenance man) stated he cleans all the rooms daily and changes linens weekly or when needed. S2 and S4 stated they are not responsible for cleaning rooms or changing linens, but common areas are cleaned always.

LPA interviewed 6 clients and 6 of 6 clients stated that the facility cleans their rooms daily and change their linens when needed. . Room #4 had uncleaned linens.

There is sufficient evidence to substantiate this allegation.

Allegation: Facility is in disrepair; it is alleged that a shower head is missing and that some client dressers and one TV is in disrepair, also that some rooms are uncleaned.

The administrator stated that all showers have shower heads. S3 stated that no shower heads are missing. S2 and S4 stated they have not heard any complaints about shower heads missing.

LPA interviewed 6 clients and 4 of 6 residents stated that all their furniture is in good repair. 6 of 6 clients stated all showers have shower heads. 2 clients stated their dressers are in disrepair. LPA inspected 14 rooms and observed Room #7, #8, #9, #10, and #13 to be unclean. There was no evidence of a broken TV. All showers had shower heads at the time of visit. Dressers in rooms #6 #8 #9, #10 are in disrepair and need to be repaired or replaced. There is sufficient evidence to substantiate this allegation.

Based on observation and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, is cited on the attached LIC 9099D.

Exit interview conducted and copy of report, 9099D and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 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
02/13/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240213092126

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:
03/01/2024
UNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Zosimo PacasioTIME COMPLETED:
12:22 PM
ALLEGATION(S):
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Staff does not ensure facility is free of pests for residents in care.
Staff are not meeting resident's grooming needs.
INVESTIGATION FINDINGS:
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Allegation: Staff does not ensure facility is free of pests for residents in care. It is alleged that the client’s rooms are infested with flies.

The licensee stated that there are no flies in the client’s room. S2 stated she does not go into rooms and does not know. S3 stated he sprays insect repellent each time he cleans the rooms to prevent insects if clients are not in the rooms. S4 denied the allegations. W1 stated that W1 does not observe flies in rooms. 6 of 6 clients could not collaborate with the allegations and LPA did not observe any flies in any of the 14 rooms inspected. There is no evidence that the clients rooms have flies.

Allegation: Staff are not meeting resident's grooming needs. It is alleged that the staff is not assisting clients with podiatrist service and one client has very long toenails with fungus.
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Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20240213092126
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: 03/01/2024
NARRATIVE
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The licensee stated that grooming is included in the services and always willing to help anyone who needs assistance. S2 stated podiatrist comes every 2 months and assists residents with podiatry services. S3 stated that some clients take care of their own podiatry needs. S4 stated that clients handle all their grooming needs. 6 of 6 clients interviewed all stated they take care of their own grooming needs including trimming their hand and toenails. R6 who is mentioned in complaint stated R6 does R6 own grooming including R6 toenail care.
There is no evidence that the clients are not being assisted with their grooming needs.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are found to be: UNSUBSTANTIATED
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240213092126
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: 03/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2024
Section Cited
CCR
85088(a)(4)
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85088 (a)(4)
Fixtures, Furniture, Equipment and Supplies

(a) In addition to Section 80088, as a condition of licensee, the following shall apply.
This requirement is not met as evidenced by:
(4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and washcloth

This requirement is not met evidenced by:
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Administrator cleared this deficiency during visit. ****Further action required****
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Room # 4 had uncleaned linens
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Type B
03/08/2024
Section Cited
CCR
85087(a)
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85087 (a)
Buildings and Grounds
The facility shall be kept clean, sanitary and in good repair at all times.

This requirement is not met evidenced by:
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Administrator will clean the rooms and repair or replace the broken dressers and send proof to LPA by POC date.
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Dressers in rooms #6 #8 #9, #10 are in disrepair and need to be repaired or replaced .LPA inspected 14 rooms and observed Room #7, #8, #9, #10, and #13 to be unclean
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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: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5