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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602243
Report Date: 08/28/2025
Date Signed: 08/28/2025 01:26:41 PM

Document Has Been Signed on 08/28/2025 01:26 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 LLCFACILITY NUMBER:
198602243
ADMINISTRATOR/
DIRECTOR:		SANDOVAL, ROSALIEFACILITY TYPE:
740
ADDRESS:1435 N GARFIELD AVETELEPHONE:
(626) 398-0527
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 60CENSUS: 32DATE:
08/28/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:24 AM
MET WITH:Naylet Velazquez, Med-Aide/Direct StaffTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Case Management Visit-Incident on 8/28/25, stemming from incident report received on 8/1/25. LPA was greeted by Elizabeth Sandoval, Medication Aide, and the purpose of the visit was explained. Naylet Velazquez, Medication Aide/Second Designee, arrived shortly after to assist with the visit. Rosalie Sandoval, Executive Director, was contacted telephonically and was also informed about the reason for the visit.

According to Unusual Incident Report (SIR) received on 8/1/2025, licensee self-reported that a resident was having sexual contact with another resident in the facility which was witnessed by a staff member who then reported the incident to the director. The incident happened on 7/24/25 in the evening. According to SIR, the incident took place at the facility between Resident 1 and Resident 2 (R1-R2). R1, indicated to staff, R2 is their friend but felt pressured by R2 to receive sexual advances which made R1 feel uncomfortable.

LPA conducted interviews with Staff 1 – Staff 4 and obtained the following information: administrative staff have talked to R2 regarding the inappropriateness of their behavior toward R1. Staff are taking extra measures to supervise the interactions between R1 and R2. Staff are also conducting more frequent checks on R1 in their room and while spending time in the common areas of the facility to ensure R1's safety. Staff further indicated, R1 is safe and well taken care of by staff and no other incident has been witnessed or reported. Telephone interview with Ombudsman indicated that they came out to the facility to do a wellness check on R1 after the incident. Ombudsman indicated that the facility did everything they are supposed to do in this type of situation. Facility notified Ombudsman, licensing and R1’s conservator/responsible party about the incident.

***Continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2025
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: 08/28/2025
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Ombudsman further indicated that R1 did not express concern regarding the incident and appeared to be in good physical and emotional state when they interviewed R1 during their visit. Ombudsman further stated, “I don’t have any concern for R1’s safety. Director is in constant communication with conservator about R1, which I was able to confirm, via phone call with them.” Ombudsman also indicated that the conservator will continue to be in communication with the facility to get wellness updates on R1. No other incident has been reported to the Ombudsman. R1 was also interviewed during today’s visit and acknowledged the incident between R1 and R2. R1 stated, R2 is their friend, but they don’t want R2 to do this again. R1 indicated, no other incident has taken place and R2 is keeping their distance. R1 further indicated, they feel safe at the facility and feel they are being cared for by the staff. R1 stated they know they can report to staff if R1 feels they are in danger. LPA was unable to conduct interview with R2 due to R2 being away at the time of visit. LPA did not observe any immediate health and safety risks during visit.

No further action is required at this time. No deficiencies were cited during this visit. Exit interview was conducted with Naylet Velazquez, Medication Aide/Second Designee. A copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
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