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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 04:15:31 PM


Document Has Been Signed on 03/29/2023 04:15 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:
04:00 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 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 the file for R1, and hospital discharge papers. LPA interviewed the Administrator. Per Administrator, on 03/19/23, R1 was found by staff on the ground on the smoking patio. Staff helped R1 up and R1 complained of pain on the elbow. When staff questioned R1 about what happened, R1 stated they slipped off their wheelchair and bumped their elbow and the corner of their right eye. Staff called emergency personnel immediately to be checked out. Upon x-rays, R1 was diagnosed with a fractured elbow. R1 was discharged and returned to facility on the same day. On 03/20/23, Primary Care Physician, Dr. Golchini, requested R1 be transferred to Los Angeles Downtown Medical Center for physical therapy due to generalized weakness and recent falls.

LPA’s received physicians report, hospital discharge papers and needs and services.

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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