197606977-4-1-2022-28-AS-NMAN-CD3VUM-20220401164457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606977
Report Date: 04/01/2022
Date Signed: 04/01/2022 04:45:03 PM

Document Has Been Signed on 04/01/2022 04:45 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ALTA VISTA RCFE II		FACILITY NUMBER:	197606977
ADMINISTRATOR:	MARY M. ESPARRAGO		FACILITY TYPE:	740
ADDRESS:	1204 N. LOUISE STREET		TELEPHONE:	(818) 281-3234
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91207
CAPACITY:	6	CENSUS: 3	DATE:	04/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Administrator Mary Esparrago		TIME COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA) Nune Margaryan conducted an annual required visit. LPA met with Administrator Mary Esparrago, who assisted with the visit. Reason for the visit was explained. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed residents and staff files. The facility is licensed for six (6) residents over the age of 60, with a hospice waiver for two (2) residents. Hospice waiver increase requested and still pending.

There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.

LPA inspected the interior and the exterior of the facility with Administrator Mary Esparrago including but not limited to: living room, dinning room, staff / storage room, kitchen, four (4) resident bedrooms, two (2) bathrooms, laundry and backyard. All indoor and outdoor passageways are free of obstruction.

Bathrooms and bedrooms were clean and in good repair. There is a locked storage for medications in the kitchen and toxins in the laundry area. Laundry located in the back of the kitchen. The kitchen was toured. All appliances were operating properly. There was a sufficient amount of perishable and non-perishable food. Kitchen knives and sharps are stored in a locked drawer in the kitchen. The common areas including the living room and dining room are clean and have the required furniture. The backyard has a shaded area and sitting area.

Continue 809C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALTA VISTA RCFE II	FACILITY NUMBER: 197606977
	VISIT DATE: 04/01/2022

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All residents bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Both bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. The hot water was 110.2 and 113.4 degrees which is within the required 105 - 120 degrees. LPA observed fire extinguisher near the kitchen which was fully charged. Smoke detectors were observed throughout the facility. First-aid Kit is complete and located in the kitchen.

LPA reviewed residents files to confirm emergency contact is updated. LPA also reviewed staff files to confirm health screenings and fingerprint clearances. All staff files reviewed were fingerprint cleared. Residents' medications were reviewed. Medications are documented properly and stored appropriately.

Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit.

A copy of the report was provided to the Administrator.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

LIC809 (FAS) - (06/04)

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