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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603464
Report Date: 09/17/2024
Date Signed: 09/17/2024 10:06:55 AM

Document Has Been Signed on 09/17/2024 10:06 AM - 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:
09/17/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Caregiver Adela Armenta TIME VISIT/
INSPECTION COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Luis De Leon conducted a Case Management Visit-POC (Plan of Correction) on 09/17/2024, stemming from annual inspection conducted on 09/01/2024. LPA’s were greeted by Caregiver Adela Armenta and explained the purpose of the visit. LPA’s gained entry into the facility at 9:30 am. Caregiver Arnenta contacted Administrator Dallas and initially agreed to meet with LPA's. At 9:34 am, Administrator Dallas telephoned Caregiver Armenta to advise her she was no longer on her way but LPA's could leave any reports at the facility. LPA Ramirez attempted to contact Administrator Dallas and left a voicemail.

Case Management-POC findings:

On 9/1/24, LPA Ramirez conducted a required annual inspection, and nine (9) violations were observed and documented. All nine (9) violations had a correction due date of 9/9/24. As of 9/17/24, LPA Ramirez has not received corrections for the violations listed below or a request for an extension before the due date.



1. 87355(e) - Criminal Record Clearance – Type A
2. 87705(f)(2) – Care of Persons with Dementia – Type A
3. 87113 – Posting of License – Type B
4. 87303(a) - Maintenance and Operation – Type B
5. 87465(a)(6) – Incidental Medical and Dental Care – Type B
6. 87456(a)(3) – Evaluation of Suitability for Admission – Type B
7. Health & Safety Code – 1569.695(c) – Type B
8. 87608(a)(5)(B) – Postural Supports – Type B
9. 87705(I)(1)(2)(3) – Care of Persons with Dementia – Type B
As a result of the violations not being cleared by 9/9/24, LPA Ramirez will issue civil penalties in the amount of $100 per day from 9/10/24 through 9/17/24, for each violation listed above. $7,200.00 in total civil penalties were assessed today for failure to correct the violations issued on 9/1/24. Civil penalties in the amount of $100 per day, per violation, will continue to be assessed until the licensee confirms to the satisfaction of the Department that the violation has been corrected. SEE 809-C
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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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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: 09/17/2024
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Caregiver Armenta did not feel comfortable signing the report. No exit interview was conducted. Administrator Dallas was unavailable during visit. A copy of this report, LIC 421FC and appeals rights was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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