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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802917
Report Date: 02/13/2023
Date Signed: 02/15/2023 09:37:06 AM


Document Has Been Signed on 02/15/2023 09:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:RED ROSES VILLAFACILITY NUMBER:
197802917
ADMINISTRATOR:BRIAN BUENVIAJEFACILITY TYPE:
740
ADDRESS:13805 E. CREWE STREETTELEPHONE:
(562) 941-3813
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY:18CENSUS: 11DATE:
02/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Brian Buenviaje and Gloria GibsonTIME COMPLETED:
03:45 PM
NARRATIVE
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Lioensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit for the purpose of conducting the Required annual inspection. On today's visit LPA met with Administrator, Brian Buenviaje and Assistant Administrator, Gloria Gibson who assisted with the visit.

LPA Rea discussed infection control practices with Ms. Gibson, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications.

Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Passageways and exits are free of obstruction. The facility yards are well maintained. The resident bathrooms have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. The hot water temperature measured at 96.9 * F degrees . The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors/carbon monoxide detectors located throughout the facility.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit. Deficiencies on 809-D. Exit interview held and a copy of the report was provided to Assistant Administrator.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023
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 2


Document Has Been Signed on 02/15/2023 09:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: RED ROSES VILLA
FACILITY NUMBER: 197802917

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(5)(A)


This requirement is not met as evidenced by: LPA observed that Carvedilol 6.25MG tablet, and DOK 100MG capsule medication for resident #1 was not administered on 2/8/23.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 5 resident medication(s) reviewed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2023
Plan of Correction
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Administrator will provide an in service medication training for staff, and provide proof of training to LPA by POC due date.
Type A
Section Cited
CCR
87303(e)(2)


This requirement is not met as evidenced by: LPA observed that water temperature measured at 87.1 degrees F in room #10, 83.3 degrees F in room #9, and 96.9 degrees F in room #3, and 91.8 degrees F in room #4.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 4 out of 4 water temperature(s) measured which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2023
Plan of Correction
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Administrator will ensure that water temperature measures between 105 degrees F and 120 degrees F as required. Administrator will send a water log with readings for 7 days to LPA by POC due date.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023
LIC809 (FAS) - (06/04)
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