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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603123
Report Date: 04/25/2024
Date Signed: 04/25/2024 04:00:11 PM

Document Has Been Signed on 04/25/2024 04:00 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/
DIRECTOR:
AGUILERA PEREZ, MONICAFACILITY TYPE:
740
ADDRESS:379 SHARON RDTELEPHONE:
(626) 317-5071
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 6CENSUS: 5DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Veronica Hernandez, staffTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Veronica Hernandez, staff, who assisted with the visit. The facility is licensed to serve six (6) non-ambulatory residents who are ages 60 and above and approved for three (3) Hospice Waiver. Facility had dementia program on file. Annual licensing fees are current. LPA discussed the purpose of today's visit with staff and licensee.

During the visit, LPA conducted staff/resident interviews, used inspection tool, toured the facility, reviewed food supply, reviewed medications, and reviewed staff/residents records.



The facility is a single family home located in a residential neighborhood, consisted of six (6) bedrooms, three (3) bathrooms, living room, dining room, activity/sun room, laundry room, kitchen, and indoor/outdoor activity areas. Sufficient supply of perishable and non-perishable foods was observed. Medications were centrally stored, locked and inaccessible to residents in care. All the rooms are furnished with appropriate furniture for residents’ comfort. Bathrooms are furnished with grab bars and nonskid surfaces. Hot water temperature is measured at 116.5 degrees Fahrenheit which is within Title 22 Regulation guidelines. Sufficient of linen supplies and personal hygiene supplies are observed. Auditory device alarms are operational. Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged and last service was on 12/5/23. The outdoor area has a shaped area and seating.

No deficiency was cited per California Code of Regulations, Title 22.



An exit interview was conducted. This report is discussed and provided to Licensee, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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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