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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602245
Report Date: 06/01/2023
Date Signed: 06/01/2023 02:24:34 PM


Document Has Been Signed on 06/01/2023 02:24 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:
06/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Rosalie Sandoval Administrator TIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Rosalie Sandoval administrator and explained the reason for the visit.

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, an activity room, a dining room with kitchenette, a medication room, a cover balcony in the second floor, 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.

LPA Flores conducted a tour of the facility with Rosalie Sandoval and observed the following:
Dining area is clean. Kitchenette's drawers/cabinets were observed, cleaning supplies were observed in a cabinet without a lock and accessible to the residents. Activity room was observed and the ceiling has water damage of about 3x1 feet. Five resident rooms were observed, room #70,72,82,86,87. Each room has sufficient lighting, and required furniture and bedding supplies. Room #82 was observed to have water damage of about 2x1 feet. A bathroom was observed in each bedroom and water temperature was tested between 108.9 - 122.3 degrees F., which is not within the required 105-120 degrees F. Bathroom tubs in rooms #70 and 72 were observed peeling. The second floor balcony's ceiling was also observed with water damage of about 3x3 feet. Outdoor area has shaded sitting areas. Medication room was observed inaccessible to the residents. Medication was reviewed for 5 residents. LPA reviewed 5 resident/staff files and interviewed 3 residents and 3 staff. Last fire inspections was conducted on 4/27/23. Last fire drill was conducted on 4/10/23. Fire Extinguishers were observed and last checked on 6/30/22.

Administrators certificate was observed #6012456740 exp date: 1/24/24. A copy of liability insurance was requested.
Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Rosalie Sandoval administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
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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Document Has Been Signed on 06/01/2023 02:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LLC
FACILITY NUMBER: 198602245

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in water temperature in bathroom's sink in room #87 was tested at 122.3 and in room #86 was tested at 121.7 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Administrator will adjust water heater and will certify on LIC 9098 that will ensure water temperature is maintain within the required 105-120 degrees F. by POC due date 6/2/23. A daily temperature log will be maintain for the rooms above for 7 days and submit to the department by 6/9/23.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in cleaning supplies were observed in kitchenette's cabinet without a lock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Administrator removed the items during the visit. Deficiency cleared as of 6/2/23.
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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/01/2023 02:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LLC
FACILITY NUMBER: 198602245

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87303(a)
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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in activity's room ceiling, balcony's ceiling, room #82's ceiling had water damage of about 3x2 feet or less which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2023
Plan of Correction
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Administrator will schedule repairs for the ceiling and submit pictures of repairs to the department by POC due date 6/15/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
LIC809 (FAS) - (06/04)
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