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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603123
Report Date: 04/28/2022
Date Signed: 04/28/2022 03:00:06 PM

Document Has Been Signed on 04/28/2022 03:00 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:ROSE VALLEY ARCADIAFACILITY NUMBER:
198603123
ADMINISTRATOR:AGUILERA PEREZ, MONICAFACILITY TYPE:
740
ADDRESS:379 SHARON RDTELEPHONE:
(626) 317-5071
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 6CENSUS: 6DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Monica AguileraTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst's (LPA's) Vasallo and Pena conducted an annual required visit. LPA's met with Administrator, Monica Aguilera and explained the reason for the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the physical plant, COVID-19 procedures, reviewed residents' medications and records, observed food supply, and reviewed staff records. The facility cares for elderly residents and is approved for 3 hospice residents. There are currently 2 residents on hospice.

All resident bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The hot water was 116.6 degrees which is within the required 105 - 120 degrees. Cleaning supplies are inaccessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the living room and dining area. These areas are clean and have the required furniture. There is a screening station at the entrance of the home which has PPEs and a thermometer to screen visitors. Staff document resident temperatures daily and require visitors to sign in. Facility currently has at least a 30-day supply of PPEs. Visitation is allowed in bedrooms, common areas and outside patio.

LPA reviewed 6 resident records to confirm emergency contact is updated. Staff records were reviewed to confirm health screenings, training and fingerprint clearances. Staff #1 (S1) did not have a health screening on file. LPA reviewed 6 residents' medications. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, the deficiency observed during the visit is documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided to Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/28/2022 03:00 PM - It Cannot Be Edited


Created By: Tony Vasallo On 04/28/2022 at 02:46 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: ROSE VALLEY ARCADIA
FACILITY NUMBER: 198603123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above in 1 out of 4 staff files which poses a potential health, safety or personal rights risk to persons in care. Staff #1 (S1) did not have a health screening on file.
POC Due Date: 05/12/2022
Plan of Correction
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Facility will submit proof of health screening for S1 by POC due date 5/12/22.

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:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


LIC809 (FAS) - (06/04)
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