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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603255
Report Date: 01/31/2022
Date Signed: 01/31/2022 03:08:11 PM

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 GARFIASFACILITY NUMBER:
198603255
ADMINISTRATOR:HSU, MICHAELFACILITY TYPE:
740
ADDRESS:2346 GARFIAS DRTELEPHONE:
(626) 486-2663
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:6CENSUS: 5DATE:
01/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Monica Aguilera, AdministratorTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lopez conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA was greeted by Ana Gasper and explained the purpose of the visit. Administrator Monica Aguilera-Perez arrived shortly after. There are 5 residents 60 and older. The facility has an approved fire clearance for six (6) non-ambulatory residents and zero (0) ambulatory / bedridden resident. The facility is a single-story home with six (6) client’s bedrooms, four (4) bathrooms, a kitchen, a dining room, a living room, a detached garage, a backyard and a front yard located in a residential neighborhood. This facility was granted a fire clearance on 11/12/19. The last fire drill was completed on December 13, 2021. Administrator certificate expires September 9, 2022.

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility has ability to designated isolation room since all residents have their own room.
· Six (6) client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Facility is equipped with alcohol-based hand sanitizer.
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks and face shields and gloves.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
· An Emergency Disaster Plan was observed.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· Deficiencies were noted on todays visit, per Title 22 Division 6 Chapter 6. Appeals Rights discussed & a copy given during visit. (See 809D)
· Exit interview was conducted with Assistant Administrator Monica Aguilera-Perez. A copy of the report was provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
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 4
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 GARFIAS
FACILITY NUMBER: 198603255
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

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 5 out of 5 residetns which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2022
Plan of Correction
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Administrator brought the 5 resident files at time of inspection.
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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
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 GARFIAS
FACILITY NUMBER: 198603255
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview with Administrator the licensee did not comply with the section cited above in 7 of 7 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2022
Plan of Correction
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Administrator will bring personnel files over to facility and self certify that files are at facility.
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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
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 GARFIAS
FACILITY NUMBER: 198603255
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)


This requirement is not met as evidenced by: LPA Lopez observed 2 staff Ana Gasper, Giovani Escamilla working at facility and not associated to facility. Also, Giovani has to have exemption with facility in order to work at facility.
Deficient Practice Statement
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Criminal Record Clearance-per section cited, all employees must be associated to the facility.

Based on observation, interview, the licensee did not comply with the section cited above in 2 out of 2 persons which poses an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 02/01/2022
Plan of Correction
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Administrator associated both staff during inspection. Administrator will contact Sacramento in order to get the exemption to work at this home. All staff shall be properly associated to facility. Criminal Record Transfer Request-and Photo I.D. must be sent for all previous cleared individual staff and a copy kept on file for validation that request was sent.
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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4