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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 08:26:52 PM

Document Has Been Signed on 09/01/2024 08:26 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:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
06:45 PM
MET WITH:Registry- Certified Nursing Assistant Tyra RTIME VISIT/
INSPECTION COMPLETED:
08:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 09/01/2024, stemming from annual inspection conducted on 09/01/2024. LPA Ramirez was greeted by Home Care Aide Registry Staff- Tyra R. Case Management-Deficiencies findings:

LPA Ramirez returned to the facility to conduct exit interview of earlier annual inspection conducted on 9/1/2024. At approximately 5:10:pm, LPA Ramirez was greeted by Registry Staff- Tyra R. Tyra advised LPA Ramirez that Administrator Dallas had left the facility and requested LPA Ramirez call Administrator Dallas once LPA Ramirez arrived. Tyra confirmed to LPA Ramirez she was the only staff at the facility and no other staff was available to conduct exit interview. LPA Ramirez telephoned Administrator Dallas and advised her LPA was ready to conduct the exit interview. Administrator Dallas stated she was unable to meet LPA Ramirez due to feeling ill. LPA Ramirez again asked Administrator Dallas if any other staff was available to discuss deficiencies and inspection report. Administrator Dallas advised LPA Ramirez no other staff were available and began to express her disapproval with LPA Ramirez conducting an annual inspection at the facility on a Sunday; expressed that due to LPA’s unexpected weekend arrival and deficiencies discussed earlier, Administrator Dallas was now ill. LPA Ramirez advised Administrator Dallas that the report will indicate her refusal to conduct exit interview via phone or in person and will indicate “REFUSE TO SIGN” on the report. Administrator Dallas advised LPA Ramirez that she was not coming or sending anyone to meet LPA and LPA could proceed forward with any course of action.


At 5:16pm, LPA Ramirez attempted to make way to the backyard to take a picture of the facility perimeter gate that earlier was observed to be in noncompliance. LPA Ramirez advised Tyra that the facility is being cited and LPA was going to take a picture for documentation purposes. Tyra called Administrator Dallas to notify her of LPA’s intent to take a picture of the perimeter gate. Tyra advised LPA Ramirez that Administrator Dallas said to “leave now!”. LPA Ramirez could hear Administrator Dallas shouting “TELL HER TO GET OUT NOW! LEAVE RIGHT NOW!” LPA Ramirez asked Tyra to put the call on speaker so LPA Ramirez could advise Administrator Dallas of the consequences of not allowing LPA Ramirez to enter and inspect the entire premise even after proper identification and stating my purpose. LPA Ramirez could hear Administrator Dallas shout “I DON’T CARE! I DON’T WANT TO TALK TO HER! GET OUT!” LPA Ramirez collected her belongings and left the facility at 5:18pm.
An Immediate Civil Penalty of $500 was assessed due LPA Ramirez being denied entry to backyard and being asked to leave the facility by Administrator Dallas during annual inspection of facility. A copy of this report, 809-D, LIC 421IM 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
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 09/01/2024 08:26 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/01/2024 at 07:40 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/02/2024
Section Cited
CCR
87755(a)

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(a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or without advance notice.
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Licensee will allow any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or without advance notice.
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This requirement was not met as evidenced by: LPA Ramirez was denied entry to backyard to complete inspection.
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Licensee will certify a plan to address how the facility plans to comply with the above regulation. Due via email by 9/2/24.

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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)
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