198204972-10-18-2021-11-AS-JCAS-C7WUQQ-20211018154731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204972
Report Date: 10/18/2021
Date Signed: 10/18/2021 04:01:00 PM

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 DR #100
MONTERY 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: 115	DATE:	10/18/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Sandra Lopez		TIME COMPLETED:	03:05 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA met with Administrator, Sandra Lopez and conducted a risk assessment, based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. The facility is licensed for 135 non-ambulatory residents age 60 and above. No residents residing in the facility with Restricted Health Care or Dementia. LPA reviewed resident file. Facility has N-95 fit test staff with SFT secure Fit testing.

LPA met with the administrator and they both toured the inside and outside grounds of the facility. LPA’s temperature was taken. LPA observed visitors log and sanitizer at the front entrance and throughout the facility.

The two story residential facility consists of (69) room/ all bedrooms are equipped with full bathroom, Common area includes: front office, outside shaded patio area, TV/ Activity room, activity directors office, dining room, commercial kitchen, medication room, parking lot with one garage, laundry rooms available, eight (8) public restrooms, recreation/ library room, (2) storage rooms, salon, and (1) elevator in the facility, There are no security bars or weapons on the premises. LPA Observed menu posted by dinning room, activity board near front office.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance and visitors log, LPA’s temperature was taken at the med-room.

Facility is conducting daily Covid-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and over 30-day supply of PPE was observed. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the outdoor patio, option to visit in the front porch and resident bedrooms if visors are inclined to indoor visit. LPA reminded in door visits requirements; such as covid test or vaccination documentation. LPA observed staff and residents maintain 6 feet physical distancing, and all staff wear a face covering. LPA observed required postings

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: ROSECRANS VILLA RESIDENTIAL CARE	FACILITY NUMBER: 198204972
	VISIT DATE: 10/18/2021

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throughout the facility. Ten (10) bedrooms were inspected. Beds in shared bedrooms are 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Ten (10) Resident bathrooms were checked, toilets and water faucets worked properly, grab bars were secure. The water temperature measured in resident rooms #116 (111.4 degrees F) , #208 (109.9 degrees F), and #226 (114.3 degrees F). Comfortable temperature was maintained in the facility.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Centrally stored medications were observed and kept safe and locked and inaccessible. The First Aid kit was available. The facility is equipped with Fire Extinguishers fully charged and accessible, service tag observed: 02/01/2021.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

Advisory Notes with technical assistance were issued.

1. LPA did not observe printed copies of CDSS PINs available to residents and staff.
2. Visitors to check in and have temperature taken and screened at the front entrance.
3. Shared bedrooms shall have soap dispensers/ bottles instead of soap bars.
4. Visitors who request in-door visits to provide proof of covid vaccination/ covid test.
5. LPA observed dust an dirty on and around the window area and glass.

A deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Sandra Lopez.

An exit interview was conducted, and a copy of this report to be provided via email.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: ROSECRANS VILLA RESIDENTIAL CARE	FACILITY NUMBER: 198204972
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/22/2021 Section Cited	1 2 3 4 5 6 7	General Food Service Requirements The total daily diet shall be of the quality and in the quantity necessary... All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement not met as evidenced by:
	8 9 10 11 12 13 14	On 10/18/21 LPA observed food itmes such as jelly in cooking glass trays covered with wrap, itme not labeled or dated. LPA observed meats in freezer not labeled/ dated. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021

LIC809 (FAS) - (06/04)

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