198204972-10-6-2023-11-AS-AINZ-CWCTEG-20231006143955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204972
Report Date: 10/06/2023
Date Signed: 10/06/2023 02:39:59 PM

Document Has Been Signed on 10/06/2023 02:39 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ROSECRANS VILLA RESIDENTIAL CARE		FACILITY NUMBER:	198204972
ADMINISTRATOR:	SANDRA LOPEZ		FACILITY TYPE:	740
ADDRESS:	14110 CORDARY AVENUE		TELEPHONE:	(310) 675-9163
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY:	135	CENSUS: 120	DATE:	10/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Sandra Lopez/Administrator		TIME COMPLETED:	02:35 PM

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On 10/6/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Sandra Lopez/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (135) non-ambulatory elderly adults ages 60 and above.

The two-story residential facility consists of (69) room/ all bedrooms are equipped with full bathroom, common area includes: front office, TV/ Activity room, activity directors’ office, dining room, commercial kitchen, medication room, parking lot, laundry rooms, public restrooms, (2) storage rooms, and (1) elevator in the facility. There are two shaded patio areas available for residents. One is a smoking patio and the other is a nonsmoking. In both patios there are plenty of seating for residents. In the parking area there is a locked shed inaccessible to residents.

LPA Iniguez and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. A total of (10) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #230, #227, #224, #222, #215, #104, #106, #114, #121, and #124. Smoke and carbon monoxide are all operable conditions. The water temperature ranged from 109.5F° – 114.2F°. The rooms temperature ranged from 76F° – 78F°.

Evaluation Report continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ROSECRANS VILLA RESIDENTIAL CARE	FACILITY NUMBER: 198204972
	VISIT DATE: 10/06/2023

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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills was conducted on 04/25/23. Annual fire clearance performed on 3/24/2023. Working landline phones are available on-site. A review of (12) residents' service files (R1-R12) and (12) staff personnel files (S1-S12) and Medication Administration Records (MAR) were maintained in order. A copy of liability insurance was provided to LPA during annual inspection.

LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted throughout the facility.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.

An exit interview was conducted, and a copy of the Facility Evaluation Report and Appeal Rights was provided to the Administrator/ Sandra Lopez.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

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