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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204972
Report Date: 03/29/2023
Date Signed: 03/29/2023 04:16:25 PM


Document Has Been Signed on 03/29/2023 04:16 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 CAREFACILITY NUMBER:
198204972
ADMINISTRATOR:SANDRA LOPEZFACILITY TYPE:
740
ADDRESS:14110 CORDARY AVENUETELEPHONE:
(310) 675-9163
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:135CENSUS: 110DATE:
03/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sandra LopezTIME COMPLETED:
04:15 PM
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On 03/29/23, Licensing Program Analyst (LPA) Wendy Gibbs, conducted a Case Management visit in regards to an incident report that happened to Resident #1 (R1) and Resident 2 (R2) that was received via fax to CCL on 03/20/23. LPA met with Administrator Sandra Lopez and explained the purpose of todays visit.

During todays visit, LPA and Administrator toured the facility. LPA reviewed R1 and R2's files and interviewed the Administrator, R1 and R2. Per Administrator, on 03/17/23, R1 walked over to R2, who was in the TV room, and hit him in the face with a closed fist. Administrator witnessed the incident from the office. Emergency personnel were call immediately, EMT and Hawthorne Police Department both responded. R2 was examined by EMT, and stated that they were okay and refused being transferred to Emergency Room. R1 and R2 were both questioned by Hawthorne Police Officer and a report was taken. Per R1's psychiatrist, Dr. Johnson, R1 was transferred to Los Angeles Downtown Medical Center and placed on a 5150 hold.
R1 returned to the facility on 03/28/23.
LPA's interview with R1 and R2 revealed R1 was upset because R2 broke their cell phone. R1 and R2 state they are both okay with each other. R2 stated that they feel safe and does not feel threatened by R1 being back in the facility. R1 and R2 both stated their is no issue between the two of them. R said they were reminded of the rules and that if they need assistance to go get staff and to use their words.

No deficiencies were cited at this time.

An exit interview was conducted and a copy of this report was provided to Administrator, Sandra Lopez.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
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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