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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602245
Report Date: 04/07/2023
Date Signed: 04/07/2023 03:55:19 PM


Document Has Been Signed on 04/07/2023 03:55 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
GREATER LA AC/SC, 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: 19DATE:
04/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administraor Rosalie SandovalTIME COMPLETED:
03:44 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management visit on 04/07/2023 at 1:38pm, regarding Special Incident Report (SIR) dated 04/05/23. LPA was greeted by Administrator Rosalie Sandoval and given a physical tour of facility.

LPA received SIR dated 04/05/23 regarding an electrical fire that occurred in resident room 89B at approximately 9:40am. LPA observed room 89B to be under construction. Facility maintenance replaced 15Amp Receptacle and Single Gang PVC nail on outlet. LPA observed a 3x2ft rectangular hole in wall above outlet. Maintenance was in the process of replacing dry wall. LPA observed two nearby night stands that contained a white powdery substance, construction debris, and dust throughout room. Per Administrator Rosalie, “replacement of wall and cleaning of furniture will be completed by 04/11/23.” Administrator Rosalie Sandoval will provide LPA with copy of Pasadena Fire Department Fire Report. LPA was provided Police Report Number: PA2023-26819. Per Administrator Rosalie, residents in shared room 89B will regain full access to their accommodation once remodeling is completed.. Residents of 89B have been temporarily re-located to room 84. LPA received invoice of electrical work performed on 04/05/23.

LPA conducted exit interview with Administrator Rosalie Sandoval.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
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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