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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603044
Report Date: 11/09/2023
Date Signed: 11/09/2023 01:06:36 PM

Document Has Been Signed on 11/09/2023 01:06 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GREEN ROSE HOME CARE CORPORATIONFACILITY NUMBER:
198603044
ADMINISTRATOR:WALKIRIA LINDA WHITFORDFACILITY TYPE:
735
ADDRESS:3324 SAN FRANCISCO AVETELEPHONE:
(562) 424-5566
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY: 4CENSUS: 4DATE:
11/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Director Linda WalkiriaTIME COMPLETED:
11:34 AM
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On 11/09/23, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Director Linda Walkiria as the purpose of the visit was explained. The facility is licensed for four (4) non-ambulatory clients ages 18-59 with developmental disabilities. Hospice waiver approved for (1). Current facility census is (4). Clients are linked to the Harbor Regional Center.

The facility is a single-story structure located in a residential neighborhood and consists of the following: (4) client bedrooms, (2) client bathrooms, living room, dining room, family room, kitchen, an office , attached garage with washer and dryer/ storage area, backyard with a shaded seating area. No weapons nor bodies of water on the premises. A supply of perishable and non-perishable food was observed. Emergency Water supply is found in the garage. Toxins and knifes were observed to be stored and inaccessible to clients. Exits and walkways are free of debris/hazards. 1 fire extinguisher located in the kitchen, 1 located in the garage.

Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F..

LPA conducted a records review of 2 staff records, 2 client records, and 2 medication administration record. No discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 11/03/23, carbon monoxide and smoke detectors observed and are operational. Landline and internet were observed. During today’s visit no discrepancies were observed.

Exit interview conducted with Director Linda Walkiria, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
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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