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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602243
Report Date: 05/30/2024
Date Signed: 05/30/2024 03:24:15 PM


Document Has Been Signed on 05/30/2024 03:24 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:GARFIELD TERRACE LLCFACILITY NUMBER:
198602243
ADMINISTRATOR:SANDOVAL, ROSALIEFACILITY TYPE:
740
ADDRESS:1435 N GARFIELD AVETELEPHONE:
(626) 398-0527
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:60CENSUS: 31DATE:
05/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Rosalie Sandoval, Administrator.TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Sanjay Vaid conducted the annual inspection. LPA arrived unannounced and met with Staff, Naylet Velazquez and Administrator, Rosalie Sandoval, assisted with physical tour. 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:
Operational Requirements: The facility does not accept or retain residents with dementia. There are currently 31 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 3 random rooms to inspect #4, #27, #30. The bedrooms have the required furniture and sufficient lighting. The hot water temperature was measured in each of the bedroom's sink and shared shower rooms west, south, north. 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 time.
Residents with Special Health Needs: The facility has some residents who use oxygen. The residents who receive insulin injections are able to administer themselves.

Due to shortage of time, the staff and residents were not interviewed. The following Care Tools were completed: Operational requirements, physical plant and environment, and residents with special health needs.
No deficiencies were noted on today’s visit. Exit interview was conducted with Rosalie Sandoval administrator and a copy of this report, were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay VaidTELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024
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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