198600747-7-10-2023-28-AS-CDCN-CTLRED-20230710125721

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600747
Report Date: 07/10/2023
Date Signed: 07/10/2023 12:57:31 PM

Document Has Been Signed on 07/10/2023 12:57 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:	ARMSTEAD RESIDENTIAL FACILITY II		FACILITY NUMBER:	198600747
ADMINISTRATOR:	JESUSA VILORIA		FACILITY TYPE:	735
ADDRESS:	926 E CITRUS EDGE STREET		TELEPHONE:	(626) 334-0124
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY: 6		CENSUS: 4	DATE:	07/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jesusa Viloria, Administrator		TIME COMPLETED:	01:10 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 Analyst (LPA) Cynthia Chan conducted the annual inspection. LPA arrived unannounced and met with licensee, Jesusa Viloria. The purpose of the visit was explained. The facility is licensed to serve (6) mentally disabled adults ages 18 to 59. There are currently 4 ambulatory clients residing at the home. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility continues to clean and disinfect daily. They are using appropriate hand hygiene and using PPE supplies when necessary. The facility has submitted an Infection Control Plan. Physical Plant & Environment Safety: There are no swimming pool on the premises or items obstructing the walkways. There are 3 client bedrooms, 1 staff room, 2 bathrooms, living room, kitchen, and attached garage. The outdoor area consists of shaded area for clients to use. The fireplace is not in use and is secured by a fence. Smoke alarms and carbon monoxide detector are operable. Fire extinguisher was last inspected on 5/24/23. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Hot water temperature was measured in the bathroom sink and is within the required range of 105 – 120 degrees F. Operational Requirements: The fire clearance is approved for (6) ambulatory clients and facility is operating within their requirements. Staffing: There is sufficient staffing at the facility. Staff employed are over the ages of 18 and are fingerprint cleared and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed 2 staff files and they have the required documents such as current First Aid/CPR certification and Health Screening with Tuberculosis test results.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARMSTEAD RESIDENTIAL FACILITY II	FACILITY NUMBER: 198600747
	VISIT DATE: 07/10/2023

NARRATIVE

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Client Rights-Information: There are no clients using postural supports. They are given internet access and devices to contact families or physicians.
Client Records-Incident Reports: Client files are maintained at the facility and LPA reviewed all 4 files. They have the required documents such Admission Agreement, Physician's Report with TB test results, Weight Record, Consent forms, Client Rights, and Appraisals/Needs and Services Plan.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food is properly stored in the refrigerator. There are no clients on special diets. Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept cleaned and stored properly.
Health Related Services: The medications are centrally stored. LPA reviewed medication for all 4 Clients. Medications are administered as prescribed by the physician and documented correctly on the MAR log.
Incidental Medical Services: There are no clients with restricted health conditions.
Disaster Preparedness: The facility has the Emergency Disaster Plan posted which items such as emergency names and phone numbers, shut off valves, evacuation procedures, etc.

There are no deficiencies issued today but a Technical Assistance was given. An exit interview was held and a copy of this report was given to the licensee.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

LIC809 (FAS) - (06/04)

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