Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601951
Report Date: 03/23/2018
Date Signed 03/23/2018 02:47:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EL MOLINO ROSE VILLAFACILITY NUMBER:
198601951
ADMINISTRATOR:ANDREI KOHLERFACILITY TYPE:
740
ADDRESS:1144 N. EL MOLINO AVENUETELEPHONE:
(626) 791-4629
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:6CENSUS: 6DATE:
03/23/2018
TYPE OF VISIT:Required - 2 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Monica Ramirez PerezTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced annual inspection. LPA was allowed entry into this home by Monica Ramirez Perez. Andrei Kohler (Facility Administrator) arrived during this visit. LPA discussed the purpose of today's visit.

During today's visit, LPA observed/obtained the following:
  • Carbon Monoxide detector was tested and operable.
  • Fire Alarms were observed. Fire Extinguishers were last serviced on 05/07/17. Last fire drill was conducted on 02/02/18.
  • Food Supply: there is sufficient supply of 2 day perishables and 7 day non- perishables.
  • All food and beverages susceptible to micro-organisms are stored in covered containers at appropriate temperature.
  • Emergency supply of water is available.
  • Disinfectants, cleaning solutions and poisons are inaccessible to residents.
  • Medications are kept locked.
  • Hot water supply was measured. The water temperature in the restroom measured at 115.0*.
  • Grab bars are available for each toilet, bathtub, and shower used by residents.
  • The shower has non-skid mats.
  • Client rooms had clean linens in good repair.
  • Lighting was sufficient in rooms and hallways.
  • Temperature inside the facility was at a comfortable temperature.
  • Outdoor and indoor passageways are free and clear of obstructions.
  • Resident files were reviewed.
  • Resident medication were reviewed.
**Refer to LIC 809C for the continuation of this report**
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2018
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EL MOLINO ROSE VILLA
FACILITY NUMBER: 198601951
VISIT DATE: 03/23/2018
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  • Staff files were reviewed.
  • Staff have criminal record clearances and First Aid/CPR certified.

The following updated documents are to be submitted to LPA by 04/06/17:
  • Designation of Administrative Responsibility (LIC 308)
  • Personnel Report (LIC 500)
  • Emergency Disaster Plan (LIC 610E)
  • Articles of Incorporation/Bylaws
  • Control of Property
  • Liability Insurance Coverage

No deficiencies cited.

Exit interview conducted, copy of this report and Appeal Rights were provided to Andrei Kohler .
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2018
LIC809 (FAS) - (06/04)
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