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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601418
Report Date: 07/19/2022
Date Signed: 07/19/2022 03:04:05 PM

Document Has Been Signed on 07/19/2022 03:04 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BUENA VISTAFACILITY NUMBER:
198601418
ADMINISTRATOR:CAROLYN WESTFACILITY TYPE:
735
ADDRESS:360 ALTA PINE DRIVETELEPHONE:
(626) 791-2516
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 6CENSUS: 4DATE:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Shequita PorterTIME COMPLETED:
03:11 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with Shequita Porter for a One (1) Year Required - Infection Control visit. LPA explained the reason for the visit. A physical plant tour was conducted at 1:00pm and the following was noted: There is one entrance being utilized at the facility, there are required posters at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Hand washing, coughing etiquette, physical distancing and other necessary signs are posted in the bathroom and throughout the facility. The facility has enough PPE supplies. The facility has a total of three (3) bedrooms and two (2) bathrooms. The facility is fire cleared for six (6) ambulatory residents. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility has a swimming pool that permanently is covered. The garage is currently being used for storage and laundry. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. The living and dining room are neat and clean with appropriate furniture. The facility maintains a comfortable temperature at 80°F. The smoke detectors observed to be operational. The residents' rooms are adequately furnished with appropriate lighting system. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 116.8°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication and first aid kit to be locked and inaccessible to residents. The facility is currently following all infection control protocols. Exit interview conducted and a copy of this report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
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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