197802917-7-29-2024-28-AS-CWOG-D7MRH8-20240729130156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802917
Report Date: 07/29/2024
Date Signed: 07/29/2024 01:04:06 PM

Document Has Been Signed on 07/29/2024 01:04 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:	RED ROSES VILLA		FACILITY NUMBER:	197802917
ADMINISTRATOR:	BRIAN BUENVIAJE		FACILITY TYPE:	740
ADDRESS:	13805 E. CREWE STREET		TELEPHONE:	(562) 941-3813
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90605
CAPACITY:	18	CENSUS: 16	DATE:	07/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Brian Buenviaje		TIME COMPLETED:	01:15 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) Wong and Nurse Consultant Olive Divranos conducted the Unannounced required annual inspection. LPA arrived unannounced and met with Administrator Brian Buenviaje and assisted with the visit. The purpose for the visit was explained. The facility is licensed for age 60 years and above and all may be non-ambulatory. Currently, the facility has 0 hospice waiver residents and 0 home health residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting once a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan in place. All staff have the health screening and chest x ray result in file. 2. Operational Requirement: The current plan of operation is completed. A fire clearance approved for 18 residents to be non-ambulatory. LPA obtained the updated copy of facility Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($3,000,000) is in place. 3. Physical Plant and Environmental Safety: The facility has two single story buildings in the facility lot. The facility is shared with the Adult Residential Facility (ARF) . The RCFE side has a dining area /TV area, with 9 bedrooms (two beds in each room) there are shared bathrooms between rooms; office; kitchen; extra office/storage room. LPA inspected four (4) rooms which include Room#9, #10 and #3 and #4. There is sufficient closet & drawer space in the bedrooms and all bedrooms have required furniture. There is sufficient closet & drawer space in the bedrooms and all bedrooms have required furniture. Beds are equipped with required linen. The hot water temperature was tested between 111.2 and 121.7 degrees F which is over the Title 22 regulation. There are grab bars near the toilet and in the showers and there is a non-skid mat in bathrooms. Residents are provided with their own soap & hand towels. There is a sufficient supply of extra linen. The washer & dryer are located in the rear of the facility. Laundry soap is locked in a cabinet above the washer & dryer. LPA inspected the smoke detectors and they are all working well. LPA also inspected the carbon monoxide detector is mounted on the wall near Room#9 and it's working properly.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

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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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: RED ROSES VILLA	FACILITY NUMBER: 197802917
	VISIT DATE: 07/29/2024

NARRATIVE

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4. Staffing: The facility has sufficient staffing in the facility to provide care and supervision to residents. All staff have an updated CPR training certificate.

5. Personnel Record-Training : All staff in the facility are over 18 years old and background check cleared but one of the staff (S1) is not associated with the facility. The administrator is Brian Buenviaje and the administrator certificate is effective through 10/3/25 and he got all the required training hours. The staff files has all the required documents include: employee application, health screening and TB test result. Staff does not have any training hours in file.

6. Resident Right Information: LPA observed the required posters posted in the facility which include Long Term Care Ombudsman located on the big board near the entrance area but LPA did not observe the CCL Licensing Poster and Resident's right poster.

7. Planned Activity: Facility has sufficient space to accommodate for indoor and outdoor activity. LPA also observed the weekly activity calendar and it's posted in the facility. The facility does have an active Resident Council.

8. Food Service: The facility does not have any residents required any modified diet. The facility has ample supply for two days perishable and seven days non-perishable food supply. All the food are stored properly. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked.

9. Incidental Medical and Dental: The facility would assist and arrange resident's medical and dental care appointments and provide transportation for them. All residents medication are centrally stored in the medication office in RCFE building. LPA inspected four resident medication and four resident medication were popped up for more than 24 hour period and also for Resident#1 medication did not pop on 7/23/24.

10. Resident Record-Incident Reports: LPA reviewed four (4) residents files and all have the required documents included: Face sheet, admission agreement, medical consent , ambulatory status, physician report, pre-admission appraisal, needs and service plan and medication list.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

Page: 7 of 9

Document Has Been Signed on 07/29/2024 01:04 PM - 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
GREATER LA AC/SC, 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: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA tested the hot water temperature for bedroom#3 and #4 were between 120.7 and 121.8 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	The administrator will fix the hot water temperature immeditately and send the hot water log to LPA for 7 days till 8/5/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 9

Document Has Been Signed on 07/29/2024 01:04 PM - 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
GREATER LA AC/SC, 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: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

87355 Criminal Record Clearance e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed Staff#1 (S1) was not associated with the facility and she was hired since 1/17/22 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	The administrator will assiciate Staff#1 immediately via Guardian and send the proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

Page: 3 of 9

Document Has Been Signed on 07/29/2024 01:04 PM - 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
GREATER LA AC/SC, 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: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)

§1569.625 Staff training; legislative findings; contents b) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 10 hours of training within the first four weeks of employment and four hours annually thereafter. This training shall be administered on the job, or in a classroom setting, or any combination of the two. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed all staff does not have any training hours documented in file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	The administrator will ensure all staff will have four hours annual training and will send the proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

Page: 4 of 9

Document Has Been Signed on 07/29/2024 01:04 PM - 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
GREATER LA AC/SC, 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: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on medication review, LPA observed Resident#1 (R1) medication on dated 7/23/24 did not pop and administrator reported R1 refused the medication 7/20/24 but staff popped the wrong date which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	The administrator will ensure all resident's medication once ordered by physician is given according to physician direction, and will send the staff in service training log or medication management to LPA by POC due date.

Type A

Section Cited

CCR

87465(e)(4)

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (4) The maximum number of doses allowed in each 24-hour period. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on medication review, LPA reviewed all four residents' medication were popped more than 24 hours period which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	The administrator will ensure the maxium number of doses allowed in each 24 hours period and will send the staff in service training log to LPA by POC due date about medication managment.

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: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

Page: 8 of 9

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: RED ROSES VILLA	FACILITY NUMBER: 197802917
	VISIT DATE: 07/29/2024

NARRATIVE

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11. Disaster Preparedness: The facility does not have an updated Emergency Disaster Plan and facility has two appropriate shelter location for emergency. The last fire/Disaster drill was conducted on 7/15/2024.

12. Residents with Special Health Needs: Facility does not have any home health or hospice residents or any residents required postural support and no residents in the facility with prohibited health condition.

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 and appeal right was provided to Administrator

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

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