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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602243
Report Date: 06/12/2024
Date Signed: 06/12/2024 03:27:30 PM


Document Has Been Signed on 06/12/2024 03:27 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:
06/12/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Rosalie Sandoval, AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Sanjay Vaid conducted a subsquential visit to complete the annual inspection at 1:30PM. LPA arrived unannounced and met with Staff, Naylet Velazquez and Administrator, Rosalie Sandoval, assisted with the visit. 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. The facility currently has 2 hospice residents.

The facility is licensed to serve 40 non-ambulatory residents ages 60 and over with an approved hospice waiver for 5 residents. The facility is a 1 story building located in a residential area, it has 20 shared rooms, an activity room, a dining room with kitchenette, a medication room, and a back outdoor area. Facility does not have a kitchen and per the plan of operation they receive food prepared in their sister facility for all resident meals.

On 05/30/24 LPA reviewed 3 domains of the CARE Tools: operational requirements, physical plant and environment and residents with special health needs. On todays visit 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. 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. 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. Continued on 809 C....
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay VaidTELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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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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: GARFIELD TERRACE LLC
FACILITY NUMBER: 198602243
VISIT DATE: 06/12/2024
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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 4 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. Last fire inspections was conducted on 4/24/24. Last fire drill was conducted on 4/10/23, earthquake drill was conducted on 04/25/24.

Medication room was observed inaccessible to the residents. Medication was reviewed for 4 residents. LPA reviewed 4 resident/staff files and interviewed 4 residents and 4 staff. Administrators certificate #6012456740 is in process of renewal, post mark for renewal sent is 12/14/23. Liability Insurance policy expires 05/08/2025. Surety bond insures $8000.00 per incident dated 01/15/2016.

No deficiencies were issued today. An exit interview was held and a copy of this report was given to the administrator.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay VaidTELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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