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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600716
Report Date: 02/11/2023
Date Signed: 02/11/2023 01:52:21 PM

Document Has Been Signed on 02/11/2023 01:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VISTAS HOMEFACILITY NUMBER:
197600716
ADMINISTRATOR:JASSO,CARLOSFACILITY TYPE:
735
ADDRESS:16778 OTSEGO ST.TELEPHONE:
(818) 784-1680
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY: 4CENSUS: DATE:
02/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Collin CashmanTIME COMPLETED:
01:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced Annual Required visit to this facility. LPA's temperature taken upon entry. The administrator was contacted and authorized staff to sign.

LPA conducted a tour at 10:00 am of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

LPA was escorted to the living area. The living room area observed to have adequate furnishings, sufficient lighting and observed to be clean with adequate seating for residents. which also has office area in the corner of the living room

LPA was escorted to kitchen area. The kitchen food supply was observed and sufficient for the four (4) residents. Two (2) days of perishable fruits, vegetables, milk, and eggs observed. The freezer is stocked with meats and frozen vegetables. The kitchen was observed to be sanitary. Extra/emergency water stored under kitchen cabinet. Laundry washer and dryer in kitchen observed to be in good repair. Linen storage in laundry area observed to have adequate supply of clean linen and towels. The toxins stored and locked in cabinets across from laundry equipment and observed to be locked and inaccessible to residents.

The medication is stored in kitchen cabinet and was observed to be locked and inaccessible. The sharps are locked in kitchen drawer near medications and observed to be inaccessible. First aid store in drawers next to sharps.

There are six (6) bedrooms with four (4) bedrooms designated for residents. All bedrooms were properly furnished and had sufficient lighting. There are four (4) bathrooms and two (2) designated for residents. Each bathroom has posted “wash your hands”

(Cont to 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2023
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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Document Has Been Signed on 02/11/2023 01:52 PM - It Cannot Be Edited


Created By: Tihesha Smith On 02/11/2023 at 01:01 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VISTAS HOME
FACILITY NUMBER: 197600716

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2023
Section Cited

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(e) Faucets used by clients for personal care such as shaving, and grooming shall deliver hot water.(1)Hot water temperature controls shall be […] not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).( 2)Taps delivering water at 125 degrees F (51.6 degrees C) or above shall be prominently identified by warning signs. This requirement was not met as evidenced by:
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The licensee did not comply with the section cited above. The hot water in East Bathroom at 145.7 which is above regulation without any warning signs present. This poses an immediate health, safety risk to persons in care.

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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:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2023


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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VISTAS HOME
FACILITY NUMBER: 197600716
VISIT DATE: 02/11/2023
NARRATIVE
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(Cont. from 809)

signs and were clean, properly supplied and had functional fixtures.

The water temperature for resident bathrooms as follows: West bathroom at 118.2 Fahrenheit and East bathroom at 145.6 degrees Fahrenheit.

Smoke alarms and carbon monoxide detectors were present and function properly. There is one (1) fire extinguisher attached to kitchen/dining area wall was observed to charged.

In the backyard, a patio table, awning, and chairs observed with adequate seating. The detached garage with a locked side shed used for storage.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiency was cited (refer to LIC 809-D).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2023
LIC809 (FAS) - (06/04)
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