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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603255
Report Date: 12/15/2025
Date Signed: 12/15/2025 04:49:32 PM

Document Has Been Signed on 12/15/2025 04:49 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:ROSE VALLEY GARFIASFACILITY NUMBER:
198603255
ADMINISTRATOR/
DIRECTOR:		HSU, MICHAELFACILITY TYPE:
740
ADDRESS:2346 GARFIAS DRTELEPHONE:
(626) 486-2663
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 4DATE:
12/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:22 PM
MET WITH:Monica Aguilera, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA met with Monica Aguilera, Administrator, and the reason for the visit was explained.

The home is licensed to serve (6) non-ambulatory residents age range 60 and over; approved Hospice Waiver for (6). The home is operating within the scope of its license. There are currently (6) residents living in the facility. The home is in a residential area of Pasadena. The single-story home consists of living room, dining area, kitchen, laundry area, (6) client bedrooms, (4) full bathrooms, detached garage, front and backyard.

During today’s visit, LPA observed the following:

Furniture in the home is in good repair and there is enough seating area in the living room and dining area for residents in care. The kitchen was inspected; however, the kitchen cabinet doors were observed with grease mildew and kitchen drawers had crumbs and other food particles. The stove and small kitchen appliances are operational; however, the refrigerator was observed to be at a non-compliance temperature of 52 degrees F. and refrigerator door was not closing tightly. The home has sufficient (7) day non-perishable and (2) day perishable supply of food, but (3) ketchup bottles kept in food cabinet exceeded the “best when used” date and (1) cottage cheese container’s expiration date was 12/2/25 (in the refrigerator). Sharps/knives are kept locked in a kitchen cabinet and are inaccessible to residents in care. The bedrooms have the required furnishing and bedding. Linnen is clean and in good repair. The bathrooms are also kept clean and sanitary. Closets are spacious and kept clean.

***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: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2025
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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Document Has Been Signed on 12/15/2025 04:49 PM - It Cannot Be Edited


Created By: Mayra Cota On 12/15/2025 at 03:16 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 GARFIAS
FACILITY NUMBER: 198603255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to kitchen cabinets doors observed with grease mildew, kitchen drawers have crumbs and other food particles, laundry area was observed cluttered with bedding and towels and laundry area cabinet door hinge broken. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2025
Plan of Correction
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Administrator will send photos of cleaned kitchen door cabinets, cleaned out kitchen drawers and repaired laundry area cabinet door by POC due date. Administrator will conduct monitoring of the facility's cleanliness daily for the next week and log it. The log will be sent to LPA
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that floor in laundry area was observed cluttered with bedding, towels and clothing, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2025
Plan of Correction
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 Administrator will send photos of decluttered laundry area by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 12/15/2025 04:49 PM - It Cannot Be Edited


Created By: Mayra Cota On 12/15/2025 at 03:16 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 GARFIAS
FACILITY NUMBER: 198603255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)
Maintenance and Operation
(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on, the licensee did not comply with the section cited above due to passageway by the garage was observed with discarded mobility equipment, broken furniture and paper waste/boxes, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2025
Plan of Correction
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Administrator will order removal of all items and submit photo of cleaned area by POC due date.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to side passage way of garage being obstructed by debris like broken furniture, discarded mobility equiment and paper waste, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2025
Plan of Correction
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Administrator will order removal of all items and submit photo of cleared passage way area by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/15/2025 04:49 PM - It Cannot Be Edited


Created By: Mayra Cota On 12/15/2025 at 03:16 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 GARFIAS
FACILITY NUMBER: 198603255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that one container of cottage cheese was observed with an expiration date of 12/2/2025, one ketchup and one mustard bottle observed with "best if used date" of 10/28/25 and 8/20/25, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2025
Plan of Correction
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Items were removed from the cabinet and refirgerator and discarded at the time of visit.
Type B
Section Cited
CCR
87555(b)(21)
General Food Service Requirements

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to: refrigerator temperature was observed at 52 degrees F. and refrigerator door did not close tightly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2025
Plan of Correction
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Administrator will send LPA, service invoice of the repairs on the refrigerator. Also, administrator will log the temperatures daily and send LPA photos of the log and thermostat until POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 12/15/2025 04:49 PM - It Cannot Be Edited


Created By: Mayra Cota On 12/15/2025 at 03:55 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 GARFIAS
FACILITY NUMBER: 198603255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87407(e)(1)
87407(e)(1) Administrator Recertification Requirements
(e) To apply for recertification after the expiration date of the certificate, but within four (4) years of the certificate expiration date, the certificate holder shall submit to the Department’s Administrator Certification Section: (1) A completed Application for Administrator Certification form LIC 9214.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that Staff 1's facility file did not contain a current Administrator Certificate and certificate on file expired on 9/2025. Check on CCL application status did not have a pendding application for Staff 1, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2025
Plan of Correction
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Administrator will send LPA, proof of submission of Administrator Certificate application by forms of certified mail receipt and a copy of the application by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
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: ROSE VALLEY GARFIAS
FACILITY NUMBER: 198603255
VISIT DATE: 12/15/2025
NARRATIVE
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The water was tested in the (4) bathrooms and (1) out of (4) measured between 105-120 degrees F., and (3) bathrooms had the warning signage for water delivering above 120 degrees F. Laundry appliances are operable; however, floors in laundry area were observed cluttered with bedding, towels and clothing. Detergents are kept locked in laundry area cabinet. The facility has two fire extinguishers which are kept charged. Both fire extinguishers were inspected on 2/14/25. The home is equipped with smoke and carbon monoxide detectors which were tested and observed to be working properly. The garage is clean and kept locked; however, side passageway of the garage was observed obstructed by debris like broken furniture, discarded mobility equipment and paper waste. Extra cleaning supplies are kept locked in the garage. A shaded area in the backyard is available and seating for residents was observed. No pools or bodies of water were observed.

LPA reviewed (6) resident and (4) staff files. Staff files contain the mandated documents; however, the Administrator Certificate was observed to have expired on 9/20/2025 and a check on the CCL Administrator Application look up, did not indicate proof of current certificate or pending application. Resident files contained the required documents, Hospice Care plans, and bed rail physician orders. Safety drill records were also reviewed. The home conducts drills every month. The last drill was conducted on 12/1/25 with staff participation. The Emergency Disaster Plan is up to date.

Medication is centrally stored and locked in medication cabinet in the kitchen. Medication review was conducted and found to be dispensed according to physician’s orders and documented accordingly.

During today’s visit, deficiencies were noted, and citations issued per Title 22 Regulations. Exit interview was conducted with Monica Aguilera, Administrator, and a copy of this report, LIC 809-Ds, Appeal Rights, was provided.

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

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC809 (FAS) - (06/04)
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