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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602245
Report Date: 07/21/2022
Date Signed: 07/21/2022 01:45:10 PM


Document Has Been Signed on 07/21/2022 01:45 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 VILLAS LLCFACILITY NUMBER:
198602245
ADMINISTRATOR:SANDOVAL, ROSALIEFACILITY TYPE:
740
ADDRESS:1425 N GARFIELD AVETELEPHONE:
(626) 398-3261
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:40CENSUS: 22DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Rosalie Sandoval - AdministratorTIME COMPLETED:
02:00 PM
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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 and conducted a tour of the facility.

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 2 story building located in a residential area, it has 20 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.

LPAs conducted a tour of the facility with Rosalie Sandoval administrator and observed the following:
A dining area, a common activity/ television room was observed, have sitting area to allow for social distancing. Signs and posters were observed upon entering the facility, common areas and the medication room. Medications are kept in the medication room and were locked. LPAs observed cleaning supplies and PPE supplies that were observed locked in storage cabinets. No sharp items were observed. The following rooms were observed, rooms #70,72,81 and 86, each room had sufficient lighting, bedding supplies, and furniture. Each room had their own bathroom with a sink,bathtub observed having a skid mat and grab bars and proper working toilet. Room #70 water temperature tested at 114.4 degrees F, Room#72 was tested at 112.4 degrees F, room #81 tested at 114.4 degrees F., and room #86 tested at 112.8, which is within the required 105 - 120 degrees F. Medication and files were reviewed for 3 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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