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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602925
Report Date: 11/28/2022
Date Signed: 11/28/2022 12:15:50 PM


Document Has Been Signed on 11/28/2022 12:15 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:
11/28/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Kim CommodoreTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required annual continuation visit. LPA was greeted and met by the Administrator, Kim Commodore and Med-Tech/Administrative Assistant, Ashley Ganther and explained the purpose of today's visit. Today's visit will continue to focus on Infection Control Domain. 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.

The initial annual visit was conducted by LPA Pena on 11/21/2022. During the initial visit the following was inspected, reviewed and toured:
  • The main entrance (front door) was used as the central entry point for everyone. A check in station was set up by the entrance and Covid-19 symptom screening was 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 extinguishers located around the facility were all 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.

During today's annual visit, LPA Pena along with the Administrator inspected the following:
  • Entire physical plant outdoor and indoor
  • Outdoor and indoor passageways and exit doors
  • Random residents bedrooms in main floor
  • There are cameras in the common areas, entrance, parking lot and outside of the building. There were no cameras seen in private areas.
  • Smoke and carbon monoxide detectors are operable.
  • Medication records for six (6) random residents. Medications were locked and centrally stored in a medication room located in the main floor which are inaccessible to residents.
  • Three (3) random Staff records/files. Staff files were inspected and contained the required health screenings, criminal record clearances, and training.
  • Five (5) random Resident records/files. Resident files were inspected, and emergency contact information and health screenings were up to date for all residents.

The annual required visit is complete. Per Title 22 Regulations, there were no deficiencies observed during the initial and continuation visits.

An exit interview was conducted and a copy of this report was provided to the Administrator, Kim Commodore.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022
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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