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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802895
Report Date: 10/13/2023
Date Signed: 10/13/2023 01:35:13 PM

Document Has Been Signed on 10/13/2023 01:35 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 HOMEFACILITY NUMBER:
197802895
ADMINISTRATOR:GUI-QIN ZONGFACILITY TYPE:
735
ADDRESS:3132 ROSEMEAD PLACETELEPHONE:
(626) 288-9346
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 6CENSUS: 3DATE:
10/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Guoliang Li, Administrator TIME COMPLETED:
01:47 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez made an unannounced annual inspection visit. LPA met with DSP Xiaocui Wang and Administrator Guoliang Li arrived a arrived a short time later and assisted with the visit. LPA explained the purpose of today's visit.

This is a one-story Adult Residential Facility (ARF) facility consisting of 3 client bedrooms, including 3 shared bedrooms and 3 bathrooms, kitchen, dining room, activities room, laundry section outside, medication closet, staff room located in attached garage and outdoor shaded area. This facility is licensed for a capacity of 6 clients and today's census was 3.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies. An Infection Control Plan was posted at the facility.


Physical Plant & Environment Safety: The facility is not free of debris/hazards. There are no security bars or weapons on the premises. The hot water temperature was tested, and temperature measured between 113.3 -118.0 degrees F which is within required range of 105.0 -120.0 F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are inaccessible to clients. The last Fire/Emergency Drill was 05/15/2023. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed and recently inspected.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2023
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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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 HOME
FACILITY NUMBER: 197802895
VISIT DATE: 10/13/2023
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Operational Requirements: Facility is complying.

Staffing: There appears to be sufficient staffing in the facility. CPR/First aid certificates are on file. Administrator Gui Quin Zong and Guoliang Li certificate expires on 09/08/2022 and 8/25/2022 respectively. Proof of renewal was observed by LPA. Copy of checks dated 06/15/2022 for certificate renewals were on file.

Personnel Records-Training: Staff has criminal record clearance. Staff files are maintained at the facility. Staff have current CPR/first aid training and documentation of ongoing training.


Client Rights-Information: Client personal rights poster is posted in the facility.
Client Records-Incident Reports: Client files are kept in a secure location within the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. IPP is updated for all residents.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Services: Staff designated to administer medication do have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked medication cabinet located in the kitchen. All medications are properly labeled and in their original containers. During the visit today, LPA reviewed all 3 clients' medications, all medication is administered according to doctor’s orders.
Incidental Medical Services: Facility is in compliance and has on documentation on file.
Disaster Preparedness: The facility has an updated Emergency Disaster Plan posted at facility.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

No deficiencies cited during today's visit. Technical advisory provided.

An exit interview was conducted and a copy of this report and appeal rights were provided to Administrator.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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