197610160-8-31-2021-31-AS-YAVN-C6EV6L-20210831160944

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610160
Report Date: 08/31/2021
Date Signed: 08/31/2021 04:10:28 PM

Document Has Been Signed on 08/31/2021 04:10 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ROSE SENIOR CARE, INC. #2		FACILITY NUMBER:	197610160
ADMINISTRATOR:	JEONG, SANDY		FACILITY TYPE:	740
ADDRESS:	17611 TUBA STREET		TELEPHONE:	(818) 217-4955
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY: 6		CENSUS: 0	DATE:	08/31/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Sandy Jeong		TIME COMPLETED:	04:15 PM

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Licensing Program Analyst (LPA) Yelena Avetisyan conducted a scheduled pre-licensing visit to this property at 2:00 pm and met with applicant representative Sandy Jeong. The applicant has obtained fire clearance for 6 non-ambulatory residents one of which may be bedridden.

The LPA inspected the facility for fire safety, personal accommodations, and food service. All hardwired smoke alarms and carbon monoxide detectors were tested and function properly during the visit; While testing the smoke/carbon monoxide detectors it was observed that the fire door was not closing properly. Applicant representative stated she will contact the company who did the installation for the repairs. Fire extinguisher was charged. There will be no firearms/ammunition stored on the property.

There are four bedrooms total. Two bedrooms are designed for single occupancy and two bedrooms for double occupancy. Bedroom #4 is fire cleared for one bedridden resident. There is no staff room. Administrator stated there will be awake staff at night. Each bedroom features beds with appropriate bedding, chairs, night stands, closet space and appropriate lighting. The facility has two bathrooms for resident use and one for staff and guest use. Toiletry kits for each prospective resident were also observed.

Kitchen was observed to have appropriate utensils, pots and pans, dishes and drinkware. Sharps will be kept in a locked cabinet in the kitchen.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE SENIOR CARE, INC. #2	FACILITY NUMBER: 197610160
	VISIT DATE: 08/31/2021

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Common areas include the living room and dining room that were clean, safe and appropriately furnished. The facility has an office area off the living room that contains locked cabinets where files, medications and first aid kit will be kept.

There is a separate locked laundry room off of the kitchen area where the washer and dryer are located. Detergent and other cleaning supplies will be kept in the laundry room.

The backyard, completely fenced and gated, features a table with umbrella and chairs for resident use.

LPA requested the following proof from the applicant on or before 03/05/2021:

· Documentation to confirm the repair of the fire door.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted and report issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

LIC809 (FAS) - (06/04)

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