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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600747
Report Date: 07/14/2022
Date Signed: 07/14/2022 01:37:16 PM

Document Has Been Signed on 07/14/2022 01:37 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:ARMSTEAD RESIDENTIAL FACILITY IIFACILITY NUMBER:
198600747
ADMINISTRATOR:JESUSA VILORIAFACILITY TYPE:
735
ADDRESS:926 E CITRUS EDGE STREETTELEPHONE:
(626) 334-0124
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 6CENSUS: 5DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Jesusa Viloria TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nune Margaryan conducted an annual required visit. LPA met with Administrator Jesusa Viloria and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. The physical plant was inspected along with COVID-19 procedures, medications, food supply, and clients and staff records. The facility has an approved mitigation plan on file. The facility is
licensed to serve mentally disabled adults ages 18-59.
LPA toured the home and inspected (3) client bedrooms, (1) staff bedroom, (1) client bathroom, (1) staff bathroom, kitchen, dining room, living room, office area, laundry area which located in the attached garage.
LPA observed that laundry detergent and chemicals unlocked in the garage and accessible to clients. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the backyard. Passageways and exits are free of obstruction.
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.
The kitchen was observed for the ability to prepare and serve food. Appliances in the kitchen were functional but not clean. The stove was dirty with oil stains all over. Kitchen cabinets also needed cleaning.
LPA observed an appropriate food supply of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. All sharp objects and knives are stored in the kitchen cabinet making it inaccessible to residents.

Continue 809C




SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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: ARMSTEAD RESIDENTIAL FACILITY II
FACILITY NUMBER: 198600747
VISIT DATE: 07/14/2022
NARRATIVE
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All client bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The water temperature was tested in the client bathroom and measured at 107.8 F which is within the required 105 - 120 degrees. LPA noticed that hand washing sink was not draining the water.
There is a fire extinguisher located in the kitchen and it is fully charged. Each bedroom has a smoke detector. There is a carbon monoxide detector in the hallway of the home.
LPA observed the centrally stored medication area to be locked and inaccessible to clients. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed resident files to confirm emergency contacts have been updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented and stored properly.

Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D.

Exit interview held. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2022 01:37 PM - It Cannot Be Edited


Created By: Nune Margaryan On 07/14/2022 at 12:46 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARMSTEAD RESIDENTIAL FACILITY II
FACILITY NUMBER: 198600747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Buildings and Grounds. Disinfectants, cleaning solutions, poisons, and other items that could pose a danger to clients shall be inaccessible.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the licensee did not comply with the section cited above. LPA observed that laundry detergent and chemicals unlocked in the garage and accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2022
Plan of Correction
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Citation was cleared at the time of visit. No further action is needed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/14/2022 01:37 PM - It Cannot Be Edited


Created By: Nune Margaryan On 07/14/2022 at 01:00 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARMSTEAD RESIDENTIAL FACILITY II
FACILITY NUMBER: 198600747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.
This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observation the stove in the kitchen was dirty with oil stains all over. Kitchen cabinets also needed cleaning.
The licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.



POC Due Date: 07/14/2022
Plan of Correction
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Citation was cleared at the time of visit. No further action is needed.
Type B
Section Cited
CCR
80088(e)(3)
FIXTURES, FURNITURE EQUIPMENT AND SUPPLIES: Toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating condition, and additional equipment, aids, and/or conveniences shall be provided for physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA noticed that hand washing sink in the residents bathroom was not draining the water which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
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Licensee will ensure to have the hand washing sink in the bathroom repaired. Picture will be sent / email to LPA prior to POC date.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022


LIC809 (FAS) - (06/04)
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