198602243-6-2-2023-28-AS-CDCN-CSET4P-20230602142417

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602243
Report Date: 06/02/2023
Date Signed: 06/02/2023 02:24:39 PM

Document Has Been Signed on 06/02/2023 02:24 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GARFIELD TERRACE LLC		FACILITY NUMBER:	198602243
ADMINISTRATOR:	SANDOVAL, ROSALIE		FACILITY TYPE:	740
ADDRESS:	1435 N GARFIELD AVE		TELEPHONE:	(626) 398-0527
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	60	CENSUS: 30	DATE:	06/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Naylet Velazquez, Staff		TIME COMPLETED:	02:30 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) Cynthia Chan conducted the annual inspection. LPA arrived unannounced and met with Staff, Naylet Velazquez. Administrator, Rosalie Sandoval, arrived shortly thereafter to assist. The purpose for the visit was explained. The facility is licensed to serve 60 non-ambulatory residents ages 60 and over. There is a hospice waiver approved for 5 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are continuing to clean/disinfect every 2 hours as documented. Facility has sufficient PPE supplies and has an Infection Control Plan. They are continuing to follow the strictest guidance for any infectious outbreaks. Operational Requirements: The facility does not accept or retain residents with dementia. There are currently 30 residents residing at the facility. The facility has the sufficient amount of liability insurance covering injury to residents. Physical Plant & Environment Safety: The facility has 30 resident rooms and shared bathrooms. There are no swimming pool or bodies of water at the premises. LPA selected 5 random rooms to inspect: #6, #15, #18, #31, and #32. The bedrooms have the required furniture and sufficient lighting. The hot water temperature was measured in each of the bedroom's sink. They were all within the required range of 105-120 degrees F. The smoke detector is interconnected and there is an operable carbon monoxide detector. The facility does not have a kitchen on site. Foods are cooked at the sister facility next door and is brought over during meal times. Staffing: There is sufficient staffing at the facility. The administrator's (Rosalie Sandoval) certificate expires on 1/24/24. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GARFIELD TERRACE LLC	FACILITY NUMBER: 198602243
	VISIT DATE: 06/02/2023

NARRATIVE

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Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR or first aid training and sufficient on-going training that meets the annual requirement.
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal, and Resident rights.
Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Food Service: LPA observed sufficient food supplies of 2-day perishable and a week of non-perishable items at the sister location next door. The facility stores the emergency food supplies on site.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. During the visit today, LPA reviewed 5 residents' medication and they are being administered as prescribed by the physician. Disaster Preparedness: The facility has the updated Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: The facility has some residents who use oxygen and currently one resident on hospice. The residents who receive insulin injections are able to administer themselves.

No deficiencies were issued today. An exit interview was held and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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