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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603255
Report Date: 12/15/2023
Date Signed: 12/15/2023 03:42:19 PM

Document Has Been Signed on 12/15/2023 03:42 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ROSE VALLEY GARFIASFACILITY NUMBER:
198603255
ADMINISTRATOR:HSU, MICHAELFACILITY TYPE:
740
ADDRESS:2346 GARFIAS DRTELEPHONE:
(626) 486-2663
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
12/15/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Corey Dominguez, DSP Monica Aguilera, AdministratorTIME COMPLETED:
03:56 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted continued unannounced Annual Required Visit on 12/15/2023. LPA was met by Staff Cory Dominguez and Monica Aguilera arrived a short time later and assisted with the visit. LPA explained the purpose of the visit. Facility is licensed to serve 6 residents over 60 years old. The facility cares for elderly residents and has hospice waiver for 6 residents. LPA Lopez requested copies of Personnel Report and Resident Roster (LIC 9020)

LPA did not utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today due to technical issues. Below are the domains that LPA inspected:

1, Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting each shift for high touched surface area. Facility has sufficient PPE supplies and has an Infection Control Plan.
2. Physical Plant and Environmental: The facility is a single-story house and located around a residential neighborhood area. The facility includes living room, dining area, kitchen, six clients bedrooms, two private bathrooms and 2 common bathrooms, laundry area and for storage for medications. LPA inspected the carbon monoxide detector and is working probably. The smoke detectors are in each room and common area, and they are operable. LPA tested the hot water temperature, and it tested between 108.3 - 111.3 degrees F. which are within the Title 22 regulations. All the sharp knives and utensils are locked under the kitchen sink. All the cleaning supplies and chemicals are locked in the detached garage. The facility has sufficient personal hygiene products for clients to use. All clients rooms are furnished and have required beddings. All the bathrooms are clean, sanitized, and operational. The exit and passageway are safe and free of obstruction.

Continue on 809C
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ROSE VALLEY GARFIAS
FACILITY NUMBER: 198603255
VISIT DATE: 12/15/2023
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4. Staffing: The facility has sufficient staffing, and the night supervision staff did have current CPR/first aid certification.
5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The administrator Monica Aguilera certificate expired on 09/9/2022. Administrator showed LPA canceled check for renewal of certificate dated 07/19/2023. The administrator did have an updated HIV and TB training certificate and the last one was completed on 03/2023. All the direct care staff received Medication Management Training. The first aid training certificates for staff is current.
6. Residents Right-Information: The facility does not have client that requires postural support. The facility does have internet service and provides at least one access device. Let Us Know, Ombudsman and personal rights are posted at facility.
10. Incident Medical and Dental: All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

12. Emergency Intervention: No manual restraints or seclusion are used with residents in care.

No deficiencies cited today.

Due to lack of time, LPA will complete domains 3,7,9, and 11 on another day.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC809 (FAS) - (06/04)
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