198602243-8-1-2025-28-AS-SVAD-DK5SQR-20250801140510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602243
Report Date: 07/10/2025
Date Signed: 08/01/2025 02:05:41 PM

Document Has Been Signed on 08/01/2025 02:05 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:	GARFIELD TERRACE LLC		FACILITY NUMBER:	198602243
ADMINISTRATOR/ DIRECTOR:	SANDOVAL, ROSALIE		FACILITY TYPE:	740
ADDRESS:	1435 N GARFIELD AVE		TELEPHONE:	(626) 398-0527
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY: 60		CENSUS: 34	DATE:	07/10/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:52 AM
MET WITH:	Rosalie Sandoval, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:10 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 Analysts (LPA) Sanjay Vaid and Elena Mallet conducted the annual inspection. LPAs arrived unannounced and met with Staff, Naylet Velazquez and Administrator, Rosalie Sandoval, assisted with physical tour. The purpose for the visit was explained. The facility is licensed to serve non-ambulatory residents ages 60 and over. There is a hospice waiver approved for 5 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Operational Requirements: The facility does not accept or retain residents with dementia. There are currently 34 residents residing at the facility. The facility has the sufficient amount of liability insurance covering injury to residents. Physical Plant & Environment Safety: The facility has 30 resident rooms and shared bathrooms. There are no swimming pool or bodies of water at the premises. LPAs selected 3 random rooms to inspect #6A,28A, 32B. The bedrooms have the required furniture and sufficient lighting. The hot water temperature was measured in each of the bedroom's sink and shared shower rooms. They were all within the required range of 105-120 degrees F. The smoke detector is interconnected and there is an operable carbon monoxide detector, inspection is serviced by fire service company. The facility does not have a kitchen on site. Foods are cooked at the sister facility next door and is brought over during mealtime. Fire extinguishers inspected 06/19/25. Residents with Special Health Needs: The facility has some residents who use oxygen. The residents who receive insulin injections can administer themselves. Continued on 809C..............

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025

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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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: GARFIELD TERRACE LLC	FACILITY NUMBER: 198602243
	VISIT DATE: 07/10/2025

NARRATIVE

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Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are continuing to clean/disinfect every 2 hours as documented. Facility has sufficient PPE supplies and has an Infection Control Plan. They are continuing to follow the strictest guidance for any infectious outbreaks.
Staffing: There is sufficient staffing at the facility. The administrator's (Rosalie Sandoval) certificate expires on 1/24/26. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.
Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR or first aid training and sufficient on-going training that meets the annual requirement.
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal, and Resident rights.
Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Food Service: LPA observed sufficient food supplies of 2-day perishable and a week of non-perishable items at the sister location next door. The facility stores the emergency food supplies on site.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. During the visit today, LPA reviewed 4 residents' medication, and they are being administered as prescribed by the physician.
Disaster Preparedness: The facility has the updated Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Last fire inspections were conducted on 4/24/25. Last fire drill was conducted on 4/25/25, earthquake drill was conducted on 05/24/25.

Medication room was observed inaccessible to the residents. Medication was reviewed for 4 residents. LPA reviewed 4 resident/staff files and interviewed 3 residents and 4 staff. Liability Insurance policy expires 05/08/2026.

No deficiencies were issued today. An exit interview was held and a copy of this report was given to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025

LIC809 (FAS) - (06/04)

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