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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603464
Report Date: 09/01/2024
Date Signed: 09/01/2024 06:42:35 PM

Document Has Been Signed on 09/01/2024 06:42 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:AMELIA ROSE SENIOR CARE COTTAGEFACILITY NUMBER:
198603464
ADMINISTRATOR/
DIRECTOR:		DALLAS, CHERYL Y.FACILITY TYPE:
740
ADDRESS:3210 WOLFE STTELEPHONE:
(310) 438-3978
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 6CENSUS: 5DATE:
09/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:16 AM
MET WITH:Administrator DallasTIME VISIT/
INSPECTION COMPLETED:
05:18 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit and was greeted by Administrator Cherly Dallas. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: LPA Ramirez observed a post-it note indicating the doorbell was in disrepair, however, licensee has a motion sensor to notify when visitors are at the front door. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected five (5) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. 1 out of 3 light bulbs in bathroom#1 and bathroom#2 were in disrepair. LPA Ramirez did not observe posted facility license in prominent location of the facility.

Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C).

Planned Activities: LPA Ramirez observed coloring activities, game boards and magazines in living room area.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed a facility land line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. No documented proof of emergency drills was observed. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply.


SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2024
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 9
Document is an Amendment of Original Document on 11/22/2024 07:46 AM


Created By: Kimberly Ramirez On 09/01/2024 at 01:56 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AMELIA ROSE SENIOR CARE COTTAGE
FACILITY NUMBER: 198603464

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, S4 did not have proof of criminal clearance prior to gaining employment at the facility, the licensee did not comply with the section cited above in 5 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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*24HR CORRECTION met due to S4 removing herself from the facility until criminal clearance is submitted.* Licensee will retrain staff on this regulation and send proof of re-training by 9/9/24 via email.
Request Denied
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 1 bottle of laundry sanitizer and 1 spray bottle of disinfectant spray was observed in bathrooms#1 and 2, the licensee did not comply with the section cited above in 3 out of 5 out of residents with dementia, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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*24HR CORRECTION met due to Administrator Dallas removing the chemicals and securing in staff office.*Licensee will retrain staff on this regulation and send proof of re-training by 9/9/24 via email.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 09/01/2024 06:42 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/01/2024 at 01:56 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: AMELIA ROSE SENIOR CARE COTTAGE
FACILITY NUMBER: 198603464

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87113
Posting of License
The license shall be posted in a prominent location in the licensed facility accessible to public view.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, license was not posted in prominent location in the facility, the licensee did not comply with the section cited above in 5 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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Licensee will post license in prominent location in the facility and send picture proof of posted license via email by 9/9/24.
Request Denied
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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,facility door bell is in disrepair, 1 out of 3 light bulbs in bathroom#1 and #2 were in disrepair, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and/or vistors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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Licensee will replace light bulbs and send picture proof by 9/9/24 via email.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 09/01/2024 06:42 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/01/2024 at 01:56 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: AMELIA ROSE SENIOR CARE COTTAGE
FACILITY NUMBER: 198603464

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R5 was missing centrally stored medications record, the licensee did not comply with the section cited above in 1 out of 5 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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Licensee will complete record and send proof via email by 9/9/24.
Request Denied
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R1 did not have any recent medical assessment, the licensee did not comply with the section cited above in 1 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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Licensee provide recent medical assessment for R1 and send via email by 9/9/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 09/01/2024 06:42 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/01/2024 at 01:56 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: AMELIA ROSE SENIOR CARE COTTAGE
FACILITY NUMBER: 198603464

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, no proof of documented drills for 2024, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and/or visitors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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Licensee will conduct drill and document drill according to above regulation. Proof must be submitted via email by 9/9/24.
Request Denied
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record reviewed, R2 does not have an order for full bed rails, the licensee did not comply with the section cited above in 1 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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Licensee will obtain an order for full bed rails or remove full bed rails by 9/9/24. Licensee will retrain staff on this regulation by 9/9/24 and send proof via email.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 09/01/2024 06:42 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/01/2024 at 03:13 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: AMELIA ROSE SENIOR CARE COTTAGE
FACILITY NUMBER: 198603464

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87705(I)(1)(2)(3)
87705 Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates.
(2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. (3) The licensee shall obtain a waiver from Section 87468(a)(6), to prevent residents from leaving the facility.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, combination lock was observed on perimeter fence without waiver from this licensing agency, no approval from on fire clearance inspection sheet and/or notification from Licensee's intent to lock perimeter gates, the licensee did not comply with the section cited above in 5 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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Licensee will apply for waiver by 9/9/24 or remove perimeters with locks. Picture proof must be submitted by 9/9/24 if licensee removes locks.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2024


LIC809 (FAS) - (06/04)
Page: 6 of 9
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: AMELIA ROSE SENIOR CARE COTTAGE
FACILITY NUMBER: 198603464
VISIT DATE: 09/01/2024
NARRATIVE
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Residents with Special Needs: No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be accessible to residents with Dementia in bathrooms#1 and #2. Auditory devices were observed to be in working order. LPA Ramirez observed perimeter fence gate to contain combination lock. LPA Ramirez did not observe waiver for use of locked perimeter gates.
Health Related Services/Incidental Medical Services: The medications are centrally stored in staff office and in bubble packs and/or original containers. Centrally stored medication record was not observed for R5. The facility provides incidental medical services.
Staffing: Administrator Certificate for Cherly Dallas is currently being renewed and LPA Ramirez verified its status. LPA Ramirez observed S1 & S2 providing care and supervision to residents in care upon arrival to the facility. It was later discovered S1 is not a regular employee of the facility or from Home Care Aid Registry. Interview of S1 and Administrator Dallas, revealed S1 did not obtain prior criminal clearance prior to beginning their employment at the facility. Per Administrator Dallas, S1 began their employment on 9/1/24 at 8am. LPA Ramirez confirmed S2 was hired through a Home Care Aide registry and LPA Ramirez was able to confirm S2’S staff file and criminal clearance due to S2 providing the documents on their phone. It was later discovered S1’s first name was different then Administrator Dallas originally believed it to be, and Administrator Dallas was unable to provide S1’s last name after personnel records were reviewed. An immediate civil penalty was assessed for this violation in the amount of $100.00 per day from 9/1/24 through 9/1/24.
Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required CPR and First Aid for three (3) out of the three (3) personnel records reviewed. S3 and S4 were missing required annual training. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for six (6) non-ambulatory residents, of which one (1) may be bedridden. This facility may retain no more than three (3) hospice residents. There are zero (0) residents under hospice care. Bedrooms#1-4 are approved for non-ambulatory & bedroom#5 is approved for bedridden.

Resident Records/Incident Reports: LPA reviewed Resident files for five (5) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed for four (4) out of the five (5) records reviewed. R1 was missing medical assessment. LPA Ramirez did not observe physician’s order for full bed rails in R2’s file.



Deficiencies were cited during inspection. Civil penalty was assessed during inspection. Exit interview was NOT conducted as Administrator Dallas was unavailable and refused to send designee to sign report or conduct exit interview. LPA Ramirez attempted to document deficiency with photo and was asked to leave the facility via phone by Administrator Dallas. A copy of this report, LIC 421BG, 809-D and appeals rights was provided via email.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2024
LIC809 (FAS) - (06/04)
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