<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602245
Report Date: 05/30/2024
Date Signed: 05/30/2024 02:23:19 PM


Document Has Been Signed on 05/30/2024 02:23 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
MONTEREY PARK ASC, 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: 16DATE:
05/30/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Rosalie Sandoval, AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst(s)(LPA) Sanjay Vaid 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.

Licensing Program Analyst(LPA) Sanjay Vaid conducted continuation of the annual from 05/23/24. During the last visit the following care tools utilized were : Operational Requirements, Physical Plant and Environment, Staffing, Residents rights information, Planned Activities and Food Services. On todays visit the following care tools utilized were: Infection Control, Personal Records training, Resident Rec-Incident Reports, Disaster Preparedness, Resident with SHN and Accidental M&D.

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.

Medication room was observed inaccessible to the residents. Medication was reviewed for 5 residents. LPA reviewed 5 resident/staff files and interviewed 5 residents and 4 staff. Last fire inspections was conducted on 4/02/24. Last fire drill was conducted on 4/10/23, earthquake drill was conducted on 04/25/24. Administrators certificate #6012456740 is in process of renewal, post mark for renewal sent is 12/14/23.

No deficiencies were noted on today’s visit. Exit interview was conducted with Rosalie Sandoval administrator and a copy of this report, was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay VaidTELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1