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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603044
Report Date: 07/31/2024
Date Signed: 07/31/2024 01:37:45 PM

Document Has Been Signed on 07/31/2024 01:37 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:GREEN ROSE HOME CARE CORPORATIONFACILITY NUMBER:
198603044
ADMINISTRATOR/
DIRECTOR:		WALKIRIA LINDA WHITFORDFACILITY TYPE:
735
ADDRESS:3324 SAN FRANCISCO AVETELEPHONE:
(562) 424-5566
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY: 4CENSUS: 4DATE:
07/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:31 AM
MET WITH: Director Linda WalkiriaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 07/31/24 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. Facility fees are current, there is an active surety bond with expiration date of 04/05/26.

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 , an attached garage with washer and dryer/ storage area, backyard with a shaded seating area. 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. 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.. Exits and walkways are free of debris/hazards. No weapons nor bodies of water on the premises.

LPA conducted a records review of (3) staff records, 4 client records, and 2 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 07/14/24, fire extinguishers fully charged, carbon monoxide and smoke detectors were observed and are operational.

Deficiencies cited on 809D page.

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: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
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 07/31/2024 01:37 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 07/31/2024 at 01:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GREEN ROSE HOME CARE CORPORATION
FACILITY NUMBER: 198603044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
80075(f)
80075 health related services

Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as first aid/CPR verification for (S1) was not available at the time of inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2024
Plan of Correction
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Director to provide proof to LPA of active first aide/CPR for S1 by POC due date.
Type B
Section Cited
CCR
80024(h)(1)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents

Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:
Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements, and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as P&I ledgers for (4) clients were not available at the time of inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2024
Plan of Correction
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Director to provide LPA with proof of up to date P&I ledgers for all (4) clients by POC due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024


LIC809 (FAS) - (06/04)
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