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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602243
Report Date: 07/21/2022
Date Signed: 07/21/2022 01:43:12 PM


Document Has Been Signed on 07/21/2022 01:43 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
CCLD Regional Office, 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: 29DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Rosalie Sandoval - AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst(s) (LPA) Mary Flores and Ashley Calderon conducted an unannounced annual visit with focus on infection control, medication, and food review. LPAs met with Rosalie Sandoval administrator and conducted a tour of the facility.

The facility is licensed to serve 60 non-ambulatory residents ages 60 and over with an approved hospice waiver for 5 residents. The facility is a large building located in a residential area, it has 35 shared rooms, and shaded sitting 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. Facility has a sprinkle smoke detector system throughout and carbon monoxide detectors were observed.

LPAs conducted a tour of the facility with Rosalie Sandoval administrator and observed the following:
Dining/Activity area was observed to have sitting set to allow for social distancing. Signs and posters were observed upon entering the facility and the office area. Medication is kept in the medication room and under lock. Cleaning supplies, PPE supplies, and emergency food supplies were observed locked in a storage room. No sharps were observed.The following rooms were observed, rooms #4,6,13,19,31,32 each room had sufficient lighting, bedding supplies, and furniture and a shared toilet. Facility has 3 common bathroom/showers(B), skid mats and grab bars were observed and B#1 water temperature was tested at 114.9 degrees F, B#2 was tested at 113.4 degrees F. unidentified animal droppings were observed in the corners of the showers, and B#3 was tested at 110.1 degrees F., which is within the required 105 - 120 degrees F. Medication and files were reviewed for 4 residents and 4 staff files. Administrator certificate was observed # 6012456740 expiration date 1/24/24.

Facility is maintaining Infection control recommendations per guidelines and recommendations.

Exit interview was conducted with Rosalie Sandoval Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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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