198602245-7-14-2021-28-AS-NMAN-C4WUKP-20210714153924

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602245
Report Date: 07/14/2021
Date Signed: 07/14/2021 03:39:39 PM

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 VILLAS LLC		FACILITY NUMBER:	198602245
ADMINISTRATOR:	SANDOVAL, ROSALIE		FACILITY TYPE:	740
ADDRESS:	1425 N GARFIELD AVE		TELEPHONE:	(626) 398-3261
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	40	CENSUS: 23	DATE:	07/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Administrator / Rosalie Sandoval Med Tech / Elizabeth Saavedra		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Nune Margaryan and Joe Katrdzhyan conducted an unannounced Annual - 1 Year Required visit to this facility. Upon arrival, LPAs met with Administrator / Rosalie Sandoval and Med Tech / Elizabeth Saavedra who assist with the visit. During today's visit, LPAs used the infection control tool to evaluate the facility.

The facility submitted an LIC 808 mitigation plan, which was approved in June of 2021.
This is a two story facility and licensed to serve 40 non- ambulatory elderly residents ages 60 and over. Garfield Villas LLC does not have an approved Dementia Care Plan in their plan of operation and does not accept residents with dementia.

LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. LPAs observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways are free of obstruction.

There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPAs were screened upon entry. All staff were observed to be wearing mask during this visit.

LPAs observed the centrally stored medication area to be locked and inaccessible to residents.
The first aid kit was observed and found to be in compliance with the Title 22 Regulations.
LPAs observed sufficient stock of PPEs and cleaning supplies which are kept in designated storage rooms that are easily accessible to staff. LPAs toured randomly selected resident rooms. All Bedrooms were furnished with required furnitures. The bathrooms were observed to be clean, operational and equipped with grab bars and non-skid mats. The hot water temperature was tested throughout the facility and measured within Title 22 Regulations guidelines.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GARFIELD VILLAS LLC	FACILITY NUMBER: 198602245
	VISIT DATE: 07/14/2021

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The kitchen was inspected. LPAs observed the commercial stove, dishwasher and other kitchen equipment to be clean and in working condition. LPAs observed sufficient supply of perishable and non-perishable foods. No pesticides or poisons were stored in the food areas. Common areas (dinning room and living room) were observed clean and properly furnished.

The following concern was observed during this visit:

At 10:47AM, LPAs observed the ceiling wall in the shared bathroom of room #79 and #78 to be in disrepair. The ceiling wall was damaged and had a hole.

The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)

An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GARFIELD VILLAS LLC	FACILITY NUMBER: 198602245
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/02/2021 Section Cited	1 2 3 4 5 6 7	Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	At 10:47AM, LPAs observed the ceiling wall in the shared bathroom of room #79 and #78 to be in disrepair. The ceiling wall was damaged and had a hole.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

LIC809 (FAS) - (06/04)

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