<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603464
Report Date: 06/28/2025
Date Signed: 06/28/2025 09:47:51 AM

Document Has Been Signed on 06/28/2025 09:47 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:
06/28/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Lakeisha Ogesby - CaregiverTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Tena Herrera conducted a case management visit to note deficiencies observed during a complaint investigation visit conducted on 4/22/25 by LPA Mary Flores. LPA met with Lakeisha Ogesby and explained the reason for the visit. LPA spoke with Cheryl Dallas (Administrator) via phone call and delivered findings.

· On 4/22/25 LPA Flores conducted a complaint investigation visit. During the visit LPA reviewed 5 residents’ medication around 12:00pm and found that in 3 out of 5 residents, resident #2,#4 and #5(R2,R4,R5) staff had initialed in the PM/evening section of 4/22/25 for dose needed to be provided in the afternoon. Per administrator, staff initial medication sheet once the medication is provided and medication was still in package and not provided to the residents.

· On 4/22/25 LPA Flores interview administrator and staff who stated Resident #3(R3) had gone out to the hospital in January of 2025 via emergency responders (911) as R3 had been feeling ill. Per administrator, did not submit an incident report as administrator did not know it was reportable to Community Care Licensing (CCLD).

Deficiencies are noted on LIC 9099D per Title 22 Regulations.

Exit interview was conducted with Lakeisha Ogesby and a copy of this report, LIC 809D, and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2025
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 3
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)
Page: 2 of 3
Document Has Been Signed on 06/28/2025 09:47 AM - It Cannot Be Edited


Created By: Tena Herrera On 06/28/2025 at 07:23 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: 06/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2025
Section Cited
CCR
87506(a)

1
2
3
4
5
6
7
87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator will provide training to staff on medication logs and create procedures to provide and record medication and provide a copy to the department by POC due date
8
9
10
11
12
13
14
Based on observation and document review licensee did not ensure staff was accurately noting the medication sheets to show current medication which poses a potential risk to the health, safety, and personal rights of the persons in care.
8
9
10
11
12
13
14
Type B
07/05/2025
Section Cited
CCR87211(a)

1
2
3
4
5
6
7
87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency …the following: (1) A written report shall be submitted … within seven days of the occurrence of any of the events …
1
2
3
4
5
6
7
Administrator will submit incident report for R3 to the department and will certify in writing that will report to the department per 87211 regulations and will submit a copy to the department by POC due date
8
9
10
11
12
13
14
Based on interviews and documents reviewed the licensee did not ensure to report R3 was taken to the hospital via emergency personnel which poses a potential risk to the health, safety, and personal rights of the persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2025


LIC809 (FAS) - (06/04)
Page: 3 of 3