Rose Valley Garfias

Allegation investigated: Staff neglect resulted in resident's unexplained fracture while in care.

Licensing Program Analyst (LPA) Daniel Konishi conducted a subsequent unannounced complaint visit in response to the above-mentioned allegations. LPA met with the Administrator, Monica Aguilera and was explained the purpose of the visit. On 06/25/2025, the initial investigation visit was conducted. The investigation consisted of the following: LPA Lopez requested a copy of the Staff roster and Resident roster and conducted a tour of facility and common areas. LPA also requested pertinent files for Resident #1 (R1). LPA observed the residents in the facility to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate Health and/or Safety concerns. Administrator stated that R1 file is not at facility. Administrator stated that a friend of the R1 took the entire file, and facility was not aware of it until LPA asked for it today. Facility cited on Case management report. Unsubstantiated During today's visit, LPA Konishi obtained the following documents: staff and resident rosters. The investigation revealed the following: in regard to the allegation, “Staff neglect resulted in resident's unexplained fracture while in care.” It is alleged that R1 sustained a bruise on the right leg and diagnosed with a fracture. This allegation was investigated by the Investigation Bureau (IB) and was assigned to Investigator Miles. LPAs reviewed IB interviews which revealed the following: On 06/10/2025, the day of discovered unexplained injuries, Witness #1 (W1) conducted a regular caregiver visit with R1 at the facility and observed swelling and a dark bruise to R1’s right leg. W1 reported and photographed the unexplained injury to R1’s family member and facility staff. The Administrator and two (2) out of two (2) staff interviewed were unable to provide any information about how R1 obtained the unexplained dark bruise and swelling on the right leg. On 06/14/2025, family member contacted 911 and R1 was transported to the hospital, where R1 presented a “right lower extremity swelling and was found to have a right tibial fracture and deep vein thrombosis (DVT/blood clot).” Per record review, it was observed that R1 was attended to daily by Home Health aides and facility staff. The cause of the fracture is unknown as there were no reported falls and staff interviewed were not sure how or when the injury occurred. Because the mechanism and timing of the injury are unclear, the Department is unable to substantiate that the injury occurred due to facility neglect or lack of care and supervision. There is not enough evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was held, and a copy of this report was provided to the Administrator, Monica Aguilera.the state’s words, verbatim · CDSS document, Mar 5, 2026 · control 28-AS-20250623164156

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA met with Monica Aguilera, Administrator, and the reason for the visit was explained. The home is licensed to serve (6) non-ambulatory residents age range 60 and over; approved Hospice Waiver for (6). The home is operating within the scope of its license. There are currently (6) residents living in the facility. The home is in a residential area of Pasadena. The single-story home consists of living room, dining area, kitchen, laundry area, (6) client bedrooms, (4) full bathrooms, detached garage, front and backyard. During today’s visit, LPA observed the following: Furniture in the home is in good repair and there is enough seating area in the living room and dining area for residents in care. The kitchen was inspected; however, the kitchen cabinet doors were observed with grease mildew and kitchen drawers had crumbs and other food particles. The stove and small kitchen appliances are operational; however, the refrigerator was observed to be at a non-compliance temperature of 52 degrees F. and refrigerator door was not closing tightly. The home has sufficient (7) day non-perishable and (2) day perishable supply of food, but (3) ketchup bottles kept in food cabinet exceeded the “best when used” date and (1) cottage cheese container’s expiration date was 12/2/25 (in the refrigerator). Sharps/knives are kept locked in a kitchen cabinet and are inaccessible to residents in care. The bedrooms have the required furnishing and bedding. Linnen is clean and in good repair. The bathrooms are also kept clean and sanitary. Closets are spacious and kept clean. ***Continues on LIC 809-C*** The water was tested in the (4) bathrooms and (1) out of (4) measured between 105-120 degrees F., and (3) bathrooms had the warning signage for water delivering above 120 degrees F. Laundry appliances are operable; however, floors in laundry area were observed cluttered with bedding, towels and clothing. Detergents are kept locked in laundry area cabinet. The facility has two fire extinguishers which are kept charged. Both fire extinguishers were inspected on 2/14/25. The home is equipped with smoke and carbon monoxide detectors which were tested and observed to be working properly. The garage is clean and kept locked; however, side passageway of the garage was observed obstructed by debris like broken furniture, discarded mobility equipment and paper waste. Extra cleaning supplies are kept locked in the garage. A shaded area in the backyard is available and seating for residents was observed. No pools or bodies of water were observed. LPA reviewed (6) resident and (4) staff files. Staff files contain the mandated documents; however, the Administrator Certificate was observed to have expired on 9/20/2025 and a check on the CCL Administrator Application look up, did not indicate proof of current certificate or pending application. Resident files contained the required documents, Hospice Care plans, and bed rail physician orders. Safety drill records were also reviewed. The home conducts drills every month. The last drill was conducted on 12/1/25 with staff participation. The Emergency Disaster Plan is up to date. Medication is centrally stored and locked in medication cabinet in the kitchen. Medication review was conducted and found to be dispensed according to physician’s orders and documented accordingly. During today’s visit, deficiencies were noted, and citations issued per Title 22 Regulations. Exit interview was conducted with Monica Aguilera, Administrator, and a copy of this report, LIC 809-Ds, Appeal Rights, was provided.the state’s words, verbatim · CDSS document, Dec 15, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alberto Lopez conducted a Health and Safety check visit in response to a personal rights allegation. LPA met with Lindsey Velasquez, caregiver and explained the reason for the visit. Administrator Monica Aguilera arrive a short time later and assisted with the visit. LPA requested R1 entire file including care plan. Administrator stated that the R1 file was taken on Monday 06/23/2025 by a friend of R1. Administrator stated R1 file was in R1 room and removed when friend came to pick up all personal belongings. LPA asked Administrator to retrieve entire R1 file and send copies to LPA within seven (7) days. Administrator agreed. Deficiency cited on 809D Exit interview conducted, copy of report, 809D and appeal rights provided.the state’s words, verbatim · CDSS document, Jun 25, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(d) · Plan of correction due date: Jul 2, 2025

87506(d) Resident Records. All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...... This requirement was not met by evidence of R1 records were not at facility when LPA requested them which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 25, 2025

Plan of correction: Administrator agreed to send all of resident's records including care plan to LPA my POC date which is 07/02/2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sanjay Vaid conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Vaid was allowed entry by DSP, Lindsey Velasquez and discussed the purpose of today's visit. LPA was screened upon entry. Monica Aguilara, Administrator arrived shortly after and assisted with the facility inspection. The facility cares for the elderly and is approved for six (6) non ambulatory and hospice waivers for six (6). There are currently six (6) residents of which three (3) are ambulatory, two (2) are non-ambulatory and one (1) hospice. This single-story home contains six (6) bedrooms, four (4) bathrooms, a living room, kitchen, dining area, backyard, and detached garage. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 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 and hospice waivers for six (6). There are currently six (6) residents of which three (3) are ambulatory, two (2) are non-ambulatory and one (1) hospice. Staff are adhering to operational requirements. Physical Plant & Environment Safety: LPAs toured facility grounds. Smoke alarms and carbon monoxide detectors were observed. Both, smoke alarms and carbon monoxide detectors were tested and operable. Fire extinguishers are located throughout the premises (service date of 04/11/24). Water temperature measured as per Title 22 regulations, within 105-120 degree F. Bathrooms had non-skid surfaces and grab bars. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Con't 809C.. Staffing: Facility has reasonable staffing; staff was observed assisting residents with their activities. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for S-1 through Staff #4 (S1-S4). Staff have their Health Screening and Tuberculosis Screening on file. Residents Rights-Information: Ombudsman posters were observed to be posted in the TV room. Planned Activities: Activity schedule/calendar is posted inside the activity room. There is an activity coordinator and activity assistant for this facility on weekly basis. Food Service: Dining area has adequate seating. Plates, cups and utensils are kept cleaned and stored properly Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Incidental M&D: The medications are centrally stored in the medication room and in bubble packs and/or original containers. Medications are administered as prescribed by the Physician. Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #4(R-4). 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, Functional Capabilities, ALW assessment and Resident Rights were observed. Disaster Preparedness: The facility has the Emergency Disaster Plan in place. Emergency drills are conducted monthly. Clients with SHN: Facility does not use manual restraints at this facility No deficiencies were noted during todays visit, copy of this report was given to Administrator, Monica Aguilara.the state’s words, verbatim · CDSS document, Dec 12, 2024

Type of visit: Case Management - Annual Continuation

LPA made subsequent visit to complete annual inspection. LPA Met with Monica Aguilera who assisted with the visit . THE (CARE) tool was not functioning for this annual inspection and LPA observed the following: Client Records/Incident Reports: Six (6) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records. Health Related Services: Clients are assisted with self-administration of prescription medications. Six (6) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked cabinet and not accessible to clients in care. Medications are given according to Physician orders. Incident Medical and Dental: LPA reviewed all 6 Resident's medication files and observed that R5 did not have refills for one medication and last item they took that medication was on 01/05/2024. Deficiency cited, exit interview conducted and copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 9, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Alberto Lopez conducted continued unannounced Annual Required Visit on 12/15/2023. LPA was met by Staff Cory Dominguez and Monica Aguilera arrived a short time later and assisted with the visit. LPA explained the purpose of the visit. Facility is licensed to serve 6 residents over 60 years old. The facility cares for elderly residents and has hospice waiver for 6 residents. LPA Lopez requested copies of Personnel Report and Resident Roster (LIC 9020) LPA did not utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today due to technical issues. Below are the domains that LPA inspected: 1, Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting each shift for high touched surface area. Facility has sufficient PPE supplies and has an Infection Control Plan. 2. Physical Plant and Environmental: The facility is a single-story house and located around a residential neighborhood area. The facility includes living room, dining area, kitchen, six clients bedrooms, two private bathrooms and 2 common bathrooms, laundry area and for storage for medications. LPA inspected the carbon monoxide detector and is working probably. The smoke detectors are in each room and common area, and they are operable. LPA tested the hot water temperature, and it tested between 108.3 - 111.3 degrees F. which are within the Title 22 regulations. All the sharp knives and utensils are locked under the kitchen sink. All the cleaning supplies and chemicals are locked in the detached garage. The facility has sufficient personal hygiene products for clients to use. All clients rooms are furnished and have required beddings. All the bathrooms are clean, sanitized, and operational. The exit and passageway are safe and free of obstruction. Continue on 809C 4. Staffing: The facility has sufficient staffing, and the night supervision staff did have current CPR/first aid certification. 5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The administrator Monica Aguilera certificate expired on 09/9/2022. Administrator showed LPA canceled check for renewal of certificate dated 07/19/2023. The administrator did have an updated HIV and TB training certificate and the last one was completed on 03/2023. All the direct care staff received Medication Management Training. The first aid training certificates for staff is current. 6. Residents Right-Information: The facility does not have client that requires postural support. The facility does have internet service and provides at least one access device. Let Us Know, Ombudsman and personal rights are posted at facility. 10. Incident Medical and Dental: All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file. 12. Emergency Intervention: No manual restraints or seclusion are used with residents in care. No deficiencies cited today. Due to lack of time, LPA will complete domains 3,7,9, and 11 on another day.the state’s words, verbatim · CDSS document, Dec 15, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lopez conducted an unannounced Required- 1 year visit, LPA met with DSP Corey Dominguez and Administrator Monica Aguilera showed up a few minutes. LPA discussed the purpose of the visit. LPA reviewed and obtained copy of staff and residents rosters. LPA did not observe any health or safety hazards during this visit. LPA used the CARE tool for the inspection. LPA observed: Food Service: Facility has sufficient perishable food for 2 days and Non Perishable food for 7 days. Due to time constraints, LPA will return on another day to complete the annual inspection. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Dec 1, 2023