198603123-6-1-2023-28-AS-BTAO-CSE27X-20230601170927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603123
Report Date: 06/01/2023
Date Signed: 06/01/2023 05:09:31 PM

Document Has Been Signed on 06/01/2023 05:09 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ROSE VALLEY ARCADIA		FACILITY NUMBER:	198603123
ADMINISTRATOR:	AGUILERA PEREZ, MONICA		FACILITY TYPE:	740
ADDRESS:	379 SHARON RD		TELEPHONE:	(626) 317-5071
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91007
CAPACITY:	6	CENSUS: 5	DATE:	06/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Michael Hsu, Licensee, and Staff#2		TIME COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Licensee, who assisted with the visit. The facility is licensed to serve six (6) non-ambulatory residents who are ages 60 and above and approved for three (3) Hospice Waiver. Facility had dementia program on file. Currently, none residents on hospice. Annual licensing fees are current. LPA discussed the purpose of today's visit with staff and licensee.

During the visit, LPA conducted staff/resident interviews, used inspection tool, toured the facility, reviewed food supply, reviewed medications, and reviewed staff/residents records.

The facility is a single story home located in a residential neighborhood, consisted of six (6) bedrooms, three (3) bathrooms, living room, dining room, activity/sun room, laundry room, kitchen, and indoor/outdoor activity areas. Medications were centrally stored, locked and inaccessible to residents in care. All the rooms are furnished with appropriate furniture for residents’ comfort. The bathrooms are furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the residents.

(-continued in LIC 809 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROSE VALLEY ARCADIA	FACILITY NUMBER: 198603123
	VISIT DATE: 06/01/2023

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Hot water temperature is in a range of 106.5 to 108.4 degrees Fahrenheit which was within Title 22 Regulation guidelines. Sufficient of linen supplies and personal hygiene supplies were observed.

All exit doors are equipped with auditory device alarms. Last fire drill was conducted on 1/2/23.

Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens and counter tops observed to be clean. Plates, cups, glasses and utensils are sufficient for the current census. A comfortable temperature of 73 degrees Fahrenheit maintained throughout the entire facility.

Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged and last service was on 12/21/22. All mandated documents and signages are posted in common areas.

Side and front yards are well maintained and free of debris. There is shaded outdoor area with ample seating. No bodies of water observed.

No deficiency was cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report is discussed and provided to Licensee, whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
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

LIC809 (FAS) - (06/04)

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