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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802284
Report Date: 08/27/2022
Date Signed: 09/02/2022 04:59:54 PM


Document Has Been Signed on 09/02/2022 04:59 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/02/2022 04:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

NARRATIVE
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***This is an amended report***
On 8/27/22 at 1:47 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility listed above. LPA explained the purpose of the visit to staff who then contacted administrator. At 2:10 pm, Victoria Thorne, Administrator, arrived and LPA explained the purpose of the visit.

LPA toured the facility with the administrator and observed the following: The facility has infection control signage at the front door and signage throughout the facility on handwashing, cough etiquette and use of masks. Upon entry to the facility, LPA was not screened, however, when the administrator arrived at 2:10 pm, LPA was screened. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms and in the kitchen. The fire extinguisher is located in the dining room. The extinguisher is fully charged and inspected on 5/12/22. At 2:50 pm, administrator states that Resident #1 (R1) has dementia. LPA confirmed on R1’s physician report. R1’s last annual medical assessment was 8/24/21. R1 is overdue for an assessment. Deficiency cited.

At 4:42 pm LPA conducted the Infection Control mitigation module with the administrator. No deficiencies cited from the module.

Exit interview conducted, deficiencies cited, and the report and appeal rights emailed to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
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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Document Has Been Signed on 08/27/2022 05:33 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ROSES ASSISTED LIVING LLC
FACILITY NUMBER: 405802284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87455(c)(3)(B)
87455 Acceptance and Retention Limitations
(c) No resident shall be accepted or retained if any of the following apply:
(3) The resident's primary need for care and supervision results from either:
(B) Dementia, unless the requirements of Section 87705, Care of Persons with Dementia, are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in one out of one identifiers which poses a potential health, safety or personal rights risk to persons in care. Licensee is retaining a dementia resident (R1) and has not met the requirements of Section 87705 Care of Persons with Dementia.
POC Due Date: 09/03/2022
Plan of Correction
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Licensee will update the facility’s Plan of Operation and submit to CCL by 9/3/22.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of one identifiers which poses a potential health, safety or personal rights risk to persons in care. LPA observed that Resident #1 (R1) lacked evidence of a current physician's report as per regulations. R1 has a primary diagnosis of dementia and the last physician's report was dated 8-24-21.
POC Due Date: 09/03/2022
Plan of Correction
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Licensee will submit a copy of the updated physician's report to CCL by 9/3/22.

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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2022
LIC809 (FAS) - (06/04)
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