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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603255
Report Date: 01/09/2024
Date Signed: 01/09/2024 12:02:01 PM

Document Has Been Signed on 01/09/2024 12:02 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:
01/09/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Monica Aguilera, AdministratorTIME COMPLETED:
10:08 AM
NARRATIVE
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LPA made subsequent visit to complete annual inspection. LPA Met with Monica Aguilera who assisted with the visit .

THE (CARE) tool was not functioning for this annual inspection and LPA observed the following:


Client Records/Incident Reports: Six (6) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records.

Health Related Services: Clients are assisted with self-administration of prescription medications. Six (6) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked cabinet and not accessible to clients in care. Medications are given according to Physician orders.

Incident Medical and Dental: LPA reviewed all 6 Resident's medication files and observed that R5 did not have refills for one medication and last item they took that medication was on 01/05/2024.

Deficiency cited, exit interview conducted and copy of report and appeal rights provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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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Document Has Been Signed on 01/09/2024 12:02 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/09/2024 at 11:33 AM
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 GARFIAS
FACILITY NUMBER: 198603255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(5)
Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(5) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Resident #5 did not receive their medication (Amiodarone) from Jan. 06, 2024, to Jan 09 2024 because facility was not able to obtain refills from husband of R5
POC Due Date: 01/10/2024
Plan of Correction
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Licensee shall submit written plan on how this will be addressed and provide additional training to all staff responsible for medication assistance and provide proof to the department by the POC date. Licensee will obtain R5 medication by POC date and send proof to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
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