198603255-12-13-2024-28-AS-SVAD-DBWSXM-20241213131609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603255
Report Date: 12/12/2024
Date Signed: 12/13/2024 01:16:33 PM

Document Has Been Signed on 12/13/2024 01:16 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ROSE VALLEY GARFIAS		FACILITY NUMBER:	198603255
ADMINISTRATOR/ DIRECTOR:	HSU, MICHAEL		FACILITY TYPE:	740
ADDRESS:	2346 GARFIAS DR		TELEPHONE:	(626) 486-2663
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	12/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:45 AM
MET WITH:	Monica Aguilara, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:15 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) Sanjay Vaid conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Vaid was allowed entry by DSP, Lindsey Velasquez and discussed the purpose of today's visit. LPA was screened upon entry. Monica Aguilara, Administrator arrived shortly after and assisted with the facility inspection. The facility cares for the elderly and is approved for six (6) non ambulatory and hospice waivers 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. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for six (6) non ambulatory and hospice waivers for six (6). There are currently six (6) residents of which three (3) are ambulatory, two (2) are non-ambulatory and one (1) hospice. Staff are adhering to operational requirements. Physical Plant & Environment Safety: LPAs toured facility grounds. Smoke alarms and carbon monoxide detectors were observed. Both, smoke alarms and carbon monoxide detectors were tested and operable. Fire extinguishers are located throughout the premises (service date of 04/11/24). Water temperature measured as per Title 22 regulations, within 105-120 degree F. Bathrooms had non-skid surfaces and grab bars. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Con't 809C..

Fernando Fierros	TELEPHONE: (323) 981-3981
Sanjay Vaid	TELEPHONE: 916-215-7924
	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: ROSE VALLEY GARFIAS	FACILITY NUMBER: 198603255
	VISIT DATE: 12/12/2024

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
26
27
28
29
30
31
32

Staffing: Facility has reasonable staffing; staff was observed assisting residents with their activities.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for S-1 through Staff #4 (S1-S4). Staff have their Health Screening and Tuberculosis Screening on file.
Residents Rights-Information: Ombudsman posters were observed to be posted in the TV room.
Planned Activities: Activity schedule/calendar is posted inside the activity room. There is an activity coordinator and activity assistant for this facility on weekly basis.
Food Service: Dining area has adequate seating. Plates, cups and utensils are kept cleaned and stored properly Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator.
Incidental M&D: The medications are centrally stored in the medication room and in bubble packs and/or original containers. Medications are administered as prescribed by the Physician.
Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #4(R-4). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Functional Capabilities, ALW assessment and Resident Rights were observed.
Disaster Preparedness: The facility has the Emergency Disaster Plan in place. Emergency drills are conducted monthly.
Clients with SHN: Facility does not use manual restraints at this facility

No deficiencies were noted during todays visit, copy of this report was given to Administrator, Monica Aguilara.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2