197602925-10-28-2024-28-AS-SVAD-DAGUFW-20241028153324

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602925
Report Date: 10/28/2024
Date Signed: 10/28/2024 03:33:35 PM

Document Has Been Signed on 10/28/2024 03:33 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ARBOR VISTA		FACILITY NUMBER:	197602925
ADMINISTRATOR/ DIRECTOR:	COMMODORE, KIM		FACILITY TYPE:	740
ADDRESS:	811 E WASHINGTON BLVD		TELEPHONE:	(626) 797-7296
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY: 69	TOTAL ENROLLED CHILDREN: 0	CENSUS: 49	DATE:	10/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:07 AM
MET WITH:	Kim Commodore-Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

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 Analysts (LPA) S Vaid conducted the required annual inspection. LPA met with Kim Commodore, Administrator and discussed the purpose of today’s visit. The facility is licensed to serve the elderly ages 60 and above. First floor only was approved for non-ambulatory, with a hospice waiver for two (2). The facility is a two story building located in a residential/commercial area and consist of 69 rooms with private bathrooms (eight of this rooms are in the second floor), dining room, living room, a kitchen, an outdoor patio. 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 first floor only approved for non-ambulatory, with a hospice waiver for two (2). 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. Four fire extinguishers are located throughout the premises (service date of 02/05/2024). 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. Staffing: Facility has reasonable staffing; staff was observed assisting residents with their activities and housekeeping duties cleaning rooms and commons areas. Continued on 809C..........

Fernando Fierros	TELEPHONE: (323) 981-3981
Sanjay Vaid	TELEPHONE: 916-215-7924
	DATE: 10/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARBOR VISTA	FACILITY NUMBER: 197602925
	VISIT DATE: 10/28/2024

NARRATIVE

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Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for S-1 through Staff #3 (S1-S3). Staff have their Health Screening and Tuberculosis Screening on file. Administrator license 7033366735 expires 10/10/2025.

Resident Rights-Information: Resident rights are included in Resident files. The let-us-no and 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. There are sufficient food supplies of 2-day perishable and 7-day of non-perishable items. The food is properly stored in the refrigerator. Posted menu observed on the refrigerator. Emergency food supply on 2nd floor.
Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin.

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. LPA reviewed four (4) residents medications, all medications are being administered as per physicians directions and orders.

Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) to 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. Resident files were inspected, and emergency contact information and health screenings were up to date for all residents.

Disaster Preparedness: The facility has the Emergency Disaster Plan in place. Safety drills held monthly and quarterly with random drills types. Three time per day on each shift.

No deficiencies noted on today's visit. Exit interview was held with Administrator.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

LIC809 (FAS) - (06/04)

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