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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603464
Report Date: 11/22/2024
Date Signed: 11/22/2024 09:34:49 AM

Document Has Been Signed on 11/22/2024 09:34 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:
11/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator DallasTIME VISIT/
INSPECTION COMPLETED:
09:35 AM
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**This is a corrected version of previous report dated 9/1/24. 809-D page was cited incorrectly. 87355(e) has been corrected to 87355(e)(1).**

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: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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: 11/22/2024
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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: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2024 09:34 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 11/22/2024 at 07:58 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: AMELIA ROSE SENIOR CARE COTTAGE
FACILITY NUMBER: 198603464

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2024
Section Cited
CCR
87355(e)(1)

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(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:
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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.
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(1) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidenced by:
S4 did not have proof of criminal clearance prior to gaining employment at the facility.
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Type A
09/09/2024
Section Cited
CCR87705(f)(2)

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(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

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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.
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such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by: 1 bottle of laundry sanitizer and 1 spray bottle of disinfectant spray was observed in bathrooms#1 and 2.
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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: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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