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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603255
Report Date: 12/01/2023
Date Signed: 12/01/2023 02:00:28 PM


Document Has Been Signed on 12/01/2023 02:00 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 GARFIASFACILITY NUMBER:
198603255
ADMINISTRATOR:HSU, MICHAELFACILITY TYPE:
740
ADDRESS:2346 GARFIAS DRTELEPHONE:
(626) 486-2663
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:6CENSUS: 6DATE:
12/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:02 AM
MET WITH:Corey Dominguez, DSP Monica Aguilera, AdministratorTIME COMPLETED:
02:08 PM
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Licensing Program Analyst (LPA) Lopez conducted an unannounced Required- 1 year visit, LPA met with DSP Corey Dominguez and Administrator Monica Aguilera showed up a few minutes. LPA discussed the purpose of the visit.


LPA reviewed and obtained copy of staff and residents rosters.

LPA did not observe any health or safety hazards during this visit.

LPA used the CARE tool for the inspection.

LPA observed:

Food Service: Facility has sufficient perishable food for 2 days and Non Perishable food for 7 days.


Due to time constraints, LPA will return on another day to complete the annual inspection.


Copy of report provided to Administrator.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2023
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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