198603255-12-3-2022-28-AS-BPEA-CLRSL5-20221203125746

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603255
Report Date: 12/03/2022
Date Signed: 12/03/2022 12:58:00 PM

Document Has Been Signed on 12/03/2022 12:58 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ROSE VALLEY GARFIAS		FACILITY NUMBER:	198603255
ADMINISTRATOR:	HSU, MICHAEL		FACILITY TYPE:	740
ADDRESS:	2346 GARFIAS DR		TELEPHONE:	(626) 486-2663
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	6	CENSUS: 6	DATE:	12/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lead Caregiver, Arianna Loera		TIME COMPLETED:	01:00 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 (LPA) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Pena was greeted by Lead Caregiver, Arianna Loera and discussed the purpose of today's visit. LPA was not screened upon entry, LPA had to ask the staff if anyone will be conducting the screening. Only then that Arianna checked LPA’s temperature and asked to sign in the visitor’s log sheet. Licensee, Michael Hsu was contacted by phone and told LPA that Administrator is not available until this afternoon and he will try to meet LPA at the facility in 1 ½ hour. The facility cares for the elderly and is approved for six (6) non ambulatory and hospice waiver for six (6). There are currently six (6) residents of which three (3) are ambulatory, two (2) are non-ambulatory and one (1) hospice. This single-story home contains six (6) bedrooms, four (4) bathrooms, a living room, kitchen, dining area, backyard, and detached garage. At 10:30am, LPA Pena and Lead Caregiver inspected the facility. Resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. The trash cans in all the bedrooms did not have lids. Bathrooms have the required grabs bars and non-skid materials. The trash cans in all the bathrooms did not have lids. The hot water readings were: Kitchen 116.5 deg F, Bathroom #1 131.6 deg F, Bathroom #2 128.9 deg F, Bathroom #3 126.7 deg F and Bathroom #4 125.5 deg F which are not within the required 105 - 120 degrees. Resident #1 is under hospice care and his bed was observed to have full-length bed rails. A written order from his physician is maintained in his resident’s record. Three (3) residents (R2-R4) are using half bed rails. A written order from a physician indicating the need for the bed rails are also maintained in the residents’ record. The kitchen was inspected at 10:33am. There is sufficient perishable and non-perishable food. All the appliances are clean and are working properly. Cleaning solutions, knives and sharps were locked and inaccessible to residents. The laundry room is located next to the kitchen and is clean and has cleaning supplies inaccessible to residents. The common areas such as living/activity room and dining room are clean and have the required furniture. *Refer to LIC 809C for the continuation of this report.****

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2022

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROSE VALLEY GARFIAS	FACILITY NUMBER: 198603255
	VISIT DATE: 12/03/2022

NARRATIVE

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The backyard has two (2) tables with chairs and are shaded. The backyard area has been designated as the visitor area during the COVID-19 pandemic. Exit doors have auditory devices that were operating at the time of the visit. There are two (2) fire extinguishers, one (1) located in the hallway and the other one in the kitchen. Fire extinguishers are fully charged and were last inspected on 4/07/2022. There are cameras in the common areas and there were no cameras seen in private areas.

Licensee Michael Hsu arrived at the facility at 10:55am and assisted with the inspection. Resident files were reviewed to confirm emergency contact is updated and residents have health screenings and or vaccinations. Staff files were not reviewed at the time of the visit due to Licensee and staff do not have access the files. Licensee stated that only the Administrator has the key to access the staff files. One of the caregivers, Waldeck Pierre has been working in the facility since April 2022 but is not associated to the facility. Residents' medications were reviewed to confirm medication is given as prescribed and is documented properly.

Pursuant to Title 22, deficiencies were cited on the attached 809D. An exit interview was conducted and a copy of this report and appeal rights were provided to the Licensee, Michael Hsu.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/03/2022 12:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 12/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in which the kitchen and four (4) bathrooms hot water readings were not within the required 105-120 deg F. which poses an immediate health, safety or personal rights risk to residentsin care. The hot water readings were: Kitchen 116.5 deg F, Bathroom #1 131.6 deg F, Bathroom #2 128.9 deg F, Bathroom #3 126.7 deg F and Bathroom #4 125.5 deg F which are not within the required 105 - 120 degrees.
	POC Due Date: 12/05/2022
	Plan of Correction
1 2 3 4	Administrator will provide CCLD a hot water log temperature for seven (7) days, starting Mon., 12/05/2022. The log will show the daily readings and will be emailed to LPA Pena no later than 12/12/2022.

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in which one (1) of the caregivers, Waldeck Pierre who was present in the facility during the visit is not associated to the facility which poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 12/05/2022
	Plan of Correction
1 2 3 4	Administrator will associate the staff in question to the facility via Guardian and provide a copy of the association list as proof. This will be emailed to LPA Pena by the 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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/03/2022 12:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 12/03/2022

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
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above in which the LPA was not able to review staff files due to the Licensee and staff do not have the key/access to the files which poses posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 12/09/2022
	Plan of Correction
1 2 3 4	Administrator will ensure that all staff records shall be available for licensing agency to inspect and the administrator will come up with a plan and send the plan to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2022

LIC809 (FAS) - (06/04)

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