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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602925
Report Date: 11/21/2022
Date Signed: 11/21/2022 05:11:44 PM


Document Has Been Signed on 11/21/2022 05:11 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:ARBOR VISTAFACILITY NUMBER:
197602925
ADMINISTRATOR:COMMODORE, KIMFACILITY TYPE:
740
ADDRESS:811 E WASHINGTON BLVDTELEPHONE:
(626) 797-7296
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:69CENSUS: 48DATE:
11/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Administrator, Kim CommodoreTIME COMPLETED:
05:15 PM
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At 4:05pm, Licensing Program Analyst (LPA) Bennette Pena conducted an annual inspection with the focus of the Infection Control Practice domain. LPA Pena met with the Administrator, Kim Commodore who allowed entry to the facility and explained the purpose of the visit. The facility is licensed to serve the elderly ages 60 and above. First floor only was approved for non-ambulatory. The current census is 48 ambulatory residents, zero (0) non-ambulatory, 26 total number of staff.
At 4:20pm, LPA and the Administrator toured the facility and observed/inspected the following:
  • This facility is a 2-story building which consists of 69 rooms, of which 62 room are located in the 1st floor and 7 rooms in the 2nd floor. Every room is a private room, no shared room
  • The main entrance (front door) is used as the central entry point for everyone. A check in station is set up by the entrance and Covid-19 symptom screening is initiated at entry, where LPA was screened.
  • COVID-19 Infection Control screening protocols and supplies, PPE supplies, and sign-in sheet were observed.
  • COVID-19 signage was placed in several areas of the facility.
  • Lobby, receiving area, dining area, kitchen rooms, living room, dining room, kitchen are all located in the first floor.
  • Staff on duty including the Administrator wore face masks.
  • Facility has 30 days of PPE supplies. PPE supplies are stored in the Emergency Food Storage Room in the 2nd floor.
  • Knives and other sharp items are stored in the kitchen drawer. The kitchen has 3 entry/exit points which are kept locked at all times.
  • Sufficient food supply of 2-day perishable and 7-day nonperishable were observed. The kitchen has 3 freezers, 2 freezer store the meats and the other freezer stores the vegetables and fruits. The kitchen has a walk in freezer and refrigerator.
  • The fire extinguisher was last inspected on 3/01/22.
  • Hot water temperature was measured in 3 random rooms and read at 108.7 deg F (Room 17), 118.2 deg. F (Room 33) and 106.9 deg F (Room 6), all are within the required range of 105-120 degree Fahrenheit.

No deficiencies observed during the time of this visit. The facility is operating within compliance. Exit interview was conducted and a copy of this report was given to the Administrator, Kim Commodore.


***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection.***
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
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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