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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801709
Report Date: 09/05/2025
Date Signed: 09/05/2025 03:59:28 PM

Document Has Been Signed on 09/05/2025 03:59 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ROSEMEAD VILLAFACILITY NUMBER:
197801709
ADMINISTRATOR/
DIRECTOR:		PASCASIO, ZOSIMOFACILITY TYPE:
735
ADDRESS:9025 GUESS STTELEPHONE:
(626) 280-4375
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 28CENSUS: 28DATE:
09/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Zosimo Pascasio Jr - Assistant Administrator.TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Assistant Administrator and explained the reason for the visit Administrator Zosimo Pascasio arrived shortly after and assisted with the visit. Facility is licensed to serve 28 adults between the ages of 18-59 years old. Facility has multiple single story buildings. It is in a residential area and consists of 14 client rooms, 5 client bathrooms and 1 staff bathroom, kitchen, dining room, Activity / TV room, laundry room, med-tech room, rear backyard, and a courtyard in the center of the property. LPA toured the facility. There are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard and courtyard in the center of the property. LPA observed cigarette's boxes and cigarette butts outside of building C. Walls and windows of the buildings were dirty and dusty. The kitchen was inspected. LPA observed all kitchen equipment to be clean and in working condition. LPA observed sufficient supply of 2 day perishable and 7 day non-perishable foods. LPA observed 4 refrigerators in the facility. Sharps are locked in the kitchen and inaccessible to residents. Smoke / Carbon monoxide detectors were in compliance and operational. 5 Fire extinguishers observed at the facility fully charged. Facility common areas: dining room, Activity / TV room are fully furnished for client use. The laundry room is at the back of building C. LPA observed laundry detergent unlocked in the laundry room. Client's bedrooms were observed and have sufficient lighting, the required furniture and bedding supplies. Bathrooms were observed in working conditions and the water temperature was tested between 75.7 - 79.5 degrees F, which is not within the required 105-120 degrees F. LPA observed that bathrooms do not have tight fitting covers for the storage of solid waste.

Continue 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/05/2025 03:59 PM - It Cannot Be Edited


Created By: Nune Margaryan On 09/05/2025 at 01:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROSEMEAD VILLA
FACILITY NUMBER: 197801709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed Laundry detergent unlocked in the laundry room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2025
Plan of Correction
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Laundry detergent locked immediately. The citation was cleared today. No further action needed.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Water temperature tested in the bathrooms between 75.7 - 79.5 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.



which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2025
Plan of Correction
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Water temperature was adjusted at the time of visit. The citation was cleared today. No further action needed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Nune Margaryan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/05/2025 03:59 PM - It Cannot Be Edited


Created By: Nune Margaryan On 09/05/2025 at 01:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROSEMEAD VILLA
FACILITY NUMBER: 197801709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed cigarette's boxes and cigarette butts outside of building C. Walls and windows of the buildings were dirty and dusty, which poses/posed a potential health, safety or personal rights risk to persons in care.

which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
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 Licensee / Administrator was agreed to deep clean the facility and send the proof before POC due date. Licensee / Administrator will ensure that the facility is clean at all the time.
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. At the time of visit LPA observed that bathrooms do not have tight fitting covers for the storage of solid waste, which poses/posed a potential health, safety or personal rights risk to persons in care.


POC Due Date: 09/05/2025
Plan of Correction
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Licensee orders new trash bins at the time of visit. Proof was provided to LPA. The citation was cleared today. No further action needed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Nune Margaryan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ROSEMEAD VILLA
FACILITY NUMBER: 197801709
VISIT DATE: 09/05/2025
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LPA observed the centrally stored medications to be locked in the Med-tech room and inaccessible to clients. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed client’s files and observed that all files are updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed. The last fire drill was conducted on 07/17/25.

Deficiencies are noted on LIC 809D.

Exit interview was conducted with Administrator Zosimo Pascasio. Copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
LIC809 (FAS) - (06/04)
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