198603334-11-18-2020-11-AS-MBRN-BVGQX3-20201118113253

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603334
Report Date: 11/10/2020
Date Signed: 11/18/2020 11:33:01 AM

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ROSEVIEW TERRACE		FACILITY NUMBER:	198603334
ADMINISTRATOR:	CHAVEZ, KAREN		FACILITY TYPE:	735
ADDRESS:	15607 S. VISALIA AVE.		TELEPHONE:	(310) 919-8272
CITY:	COMPTON	STATE: CA	ZIP CODE:	90220
CAPACITY:	6	CENSUS: 3	DATE:	11/10/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Karen Chavez		TIME COMPLETED:	03:30 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	On 11/10/20 at 2:30 PM, Licensing Program Analyst (LPA), Martessa Brown conducted an announced telephonic pre-license visit. Due to the situation surrounding the Coronavirus Disease 2019 (Covid-19), and to implement mitigation measures, today’s pre-licensing evaluation was conducted telephonically with Karen Chavez, the administrator. An application was submitted to CCLD on 7/12/2020, for Initial license for an Adult Residential Facility to serve Developmentally Disabled Adults for ages 18 to 59 years. The requested capacity is for 6 non-ambulatory. Facility is a 3 bedroom, 2 bathrooms, single-story house with a 2-car garage. The client’s bedrooms are spacious and will easily accommodate the client's furnishings. There is a backyard with a patio and attached cover tables and 6 chairs. Outdoor passageways, walkways, driveways, and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bedrooms Residents: All bedrooms are for 6 non-ambulatory clients. Bedrooms #1, #2 and #3 have beds, bedrooms consist of one chair, one-night stand, one lamp in addition to overhead lighting. There is dresser with drawers in Bedrooms #1, #2, and #3 which comply with the requirement of 8 cubic feet of space. Bathrooms: Bathrooms #1 and #2 have a working toilet, wash basins and showers. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, and bedspreads. Adequate supply of linen stored in hall closet. LIC 809-C is on the next page.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ROSEVIEW TERRACE	FACILITY NUMBER: 198603334
	VISIT DATE: 11/10/2020

NARRATIVE

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Emergency Phone Numbers, Exit Plan & Menu: The telephone system has 1 land lines. Emergency Disaster Plan was posted, "See something, Say something Let Us Know" was readily available and posted and visible in the hall way. Menu available for review located in the kitchen area. 1 Fire Extinguisher located in the kitchen. Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils will be stored in the kitchen drawer. There was enough food supply inventory; stored in kitchen refrigerator and cabinets and consists of the following: A variety of fresh and canned fruit, vegetable and meat food items. Smoke Detectors: 6 smoke detectors are battery operated & working. Carbon monoxide detector located and mounted in the hallway is operational. Appliances: Stove burners, oven, washer, and dryer working. There is 1 refrigerator in the home located in the kitchen and deep freezer. Refrigerator in the kitchen has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at 0 zero degrees Fahrenheit. The residency has 2 portable air conditioning and has a central heating. Toxins: Locked/stored in the kitchen cabinet. Water Temperature: Tested at 110.0 F. in bathroom #1 and bathroom #2 110.0 F. Medications, First-Aid Kit & Book: Medication administration records and first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, stored in locked cabinet, available for staff use but inaccessible to clients. Clients & Staff Files: Applicant will be handling cash resources of clients and has a surety bond for $1,000. Cash resources will be locked and stored with P & I Ledger, accessible to designated staff. Records of staff and clients shall be stored in a locked area and has been inspected.

LIC809-C is on the next page.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ROSEVIEW TERRACE	FACILITY NUMBER: 198603334
	VISIT DATE: 11/10/2020

NARRATIVE

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Reading Material, Games, Equipment & Materials: The facility has Ipads, games, and other recreational materials for the client's use. Activities changes have been discussed with the administrator due to Covid-19. Pool/Jacuzzi & Pets: LPAs did not observe any pet or bodies of water at the facility. Fire clearance: Fire Clearance was approved on 9-30-20 for 6 non ambulatory clients with no special instructions. LPA did not observe delayed egress, chain locks or dead bolts on exits. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gate and front exits. Component III: Component III was completed prior to visit on 11/05/20, information about how to operate the facility within substantial compliance.

An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA Martessa Brown will submit a copy of this facility evaluation report to Centralized Applications Bureau (CAB) If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020

LIC809 (FAS) - (06/04)

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