<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601951
Report Date: 05/08/2025
Date Signed: 05/09/2025 01:30:01 PM

Document Has Been Signed on 05/09/2025 01:30 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EL MOLINO ROSE VILLAFACILITY NUMBER:
198601951
ADMINISTRATOR/
DIRECTOR:		ANDREI KOHLERFACILITY TYPE:
740
ADDRESS:1144 N. EL MOLINO AVENUETELEPHONE:
(626) 660-5750
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:08 PM
MET WITH:Licensee, Andrei KohlerTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and explained the purpose of the visit LPA met with Andy and Yelly Kohler, who assisted with the inspection today. The facility is licensed for 6 residents ages 60 and over. The fire clearance is approved for Six (6) non-ambulatory residents. Currently there are zero (0) residents at the facility, three (3) residents have been re-located at facilities nearby and one (1) resident has gone home with family. The renovations to the facility for Eaton Canyon Fires caused smoke damage to the facility. Renovations for disaster readiness being implemented.
LPA utilize the Compliance and Regulatory Enforcement tools for the visit today and observed the following:

1. Infection Control. Facility has sufficient PPE supplies and has an Infection Control Plan.
2. Physical Plant and Environmental. The facility is a single-story house. The facility includes living room, dining area, kitchen, four clients’ bedrooms, 2 shared bedrooms, 2 private bedrooms, two bathrooms. Laundry area and an detached garage. LPA inspected the carbon monoxide detector and is working probably. The smoke detectors are in each room and common area, and they are working, hardwired and interconnected. Water temperature in two bathrooms and kitchen, a 105 -120 deg F. All the sharp knives and utensils are locked in the kitchen cabinet. All the cleaning supplies and chemicals are locked in the laundry room and locked in the outdoor storage. The facility has sufficient personal hygiene products for clients to use. All clients rooms are currently furnished with chairs and have required beddings. All the bathrooms are clean, sanitized, and operational. The exit and passageway is safe and clear of obstructions.
3. Operational Requirements. The facility maintained a fire clearance approved by the fire department which 6 may be non-ambulatory. Currently all the clients in the facility are non-ambulatory. The facility also has shaded area with table and chairs for client to utilize for outdoor activity. The last fire/disaster drill was conducted on 06/07/2024. Currently there are zero (0) residents at the facility. Contined on 809C...
Fernando FierrosTELEPHONE: (323) 981-3981
Sanjay VaidTELEPHONE: 916-215-7924
DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EL MOLINO ROSE VILLA
FACILITY NUMBER: 198601951
VISIT DATE: 05/08/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
4. Staffing: The facility has sufficient staffing.
5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. All the direct care staff received Medication Management Training. The first aid training certificates for staff is current and expires 12/09/2026. Licensee/Administrator certificates for Yelly and Andrei Kohler good thru 05/15/2026.
6. Resident Records-Incident Reports: Resident files are maintained at residents’ current facilities the residents are temporarily located.
7. Resident Rights-Information: The Ombudsman and CCLD poster and Residents personal rights are posted in the hallway.
8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
9. Food Service: Currently the residents are temporarily placed in other facilities and are taking their meals. The kitchen was inspected food preparation area, and storage areas were observed to be very clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas.
10. Incidental Medical & Dental: The medications are centrally stored, today no medications were reviewed. Residents are not present at the facility.
11. Disaster Preparedness: The facility has an Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, The facility conducts emergency drill on a quarterly basis for all staff and residents. Last safety drill was conducted on 06/27/24. Three (3) fire extinguishers located throughout the facility, purchased 01/28/2025.
12. Residents with Special Health Needs: No residents have prohibited health conditions.

Facility dues were paid 05/07/2025.

No deficiencies observed during today’s visit. An exit interview was held. A copy of this report was provided to licensee/administrator Andrei Kohler.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay VaidTELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3