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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204972
Report Date: 09/12/2024
Date Signed: 09/12/2024 02:49:07 PM


Document Has Been Signed on 09/12/2024 02:49 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:ROSECRANS VILLA RESIDENTIAL CAREFACILITY NUMBER:
198204972
ADMINISTRATOR:SANDRA LOPEZFACILITY TYPE:
740
ADDRESS:14110 CORDARY AVENUETELEPHONE:
(310) 675-9163
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:135CENSUS: 116DATE:
09/12/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrator - Sandra LopezTIME COMPLETED:
03:10 PM
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On 09/12/2024 at around 1:10 PM, Licensing Program Analyst (LPA) Leandro conducted an unannounced continuation Required – 1 Year Inspection to the above-named facility and met with Administrator Sandra Lopez. LPA explained the purpose of the visit and was accompanied by Administrator inside and outside the facility during this inspection.

Today's annual inspection consisted of records review: 5 staff records were reviewed, 5 out of 5 staff records had required documentation. 5 resident records were reviewed and, 5 out of 5 resident records had required documentation. Facility records were reviewed, and facility had current/required documentation.

A technical assistance is being issued for facility not having a videoconferencing device on the premises. Administrator will work with the Licensee on this issue.

No deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report was left with the Administrator.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
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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