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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601496
Report Date: 04/12/2022
Date Signed: 08/10/2022 01:42:33 PM

Document Has Been Signed on 08/10/2022 01:42 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:MONTANA VISTAFACILITY NUMBER:
198601496
ADMINISTRATOR:CAROLYN WESTFACILITY TYPE:
735
ADDRESS:355 WEST MONTANA STREETTELEPHONE:
(626) 398-8519
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 5DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Staff / Quiana Robinson
Assistant Administrator / Nancy Parker		TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Annual/Required inspection. Upon arriving at the facility, LPA met with Staff / Quiana Robinson and was later joined by the Assistant Administrator / Nancy Parker who assisted with the visit. The facility is licensed to serve six (6) Developmentally Disabled Clients ages 18 - 59 years of age. The facility is approved for six (6) Ambulatory Clients only. Currently, there are five (5) clients in placement. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed.

The facility is located in a residential area. A tour of the single-story facility includes: Three (3) client bedrooms, two (2) bathrooms, living room, kitchen, dining area, laundry area and indoor/outdoor activity areas. All medications for residents who need assistance are kept locked and inaccessible to other clients. Knives, disinfectants and cleaning solutions are kept locked and inaccessible to clients. The bathrooms are clean and operational. Client bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested throughout the facility. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. LPA reviewed client medications.

Smoke detectors and carbon monoxide detectors are operable and in compliance. LPA observed a pull-switch fire alarm behind the entrance door. The fire extinguishers (2) were fully charged and in compliance. There is a functioning telephone on the premises. The facility has central heating accommodations. The washer and dryer are located in the laundry area (near the kitchen). The first-aid kit is fully stocked w/First-aid Manual. The front yard is well landscaped with steps and/or a ramp that leads to the entry. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. The trash cans have covered lids. There is no evidence of bodies of water (pool) or
(please see LIC 809C for additional information)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: MONTANA VISTA
FACILITY NUMBER: 198601496
VISIT DATE: 04/12/2022
NARRATIVE
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security bars nor weapons on the premises. There is a detached two-car garage which is kept locked and inaccessible to clients.

The following deficiencies were observed during today's visit;
  • Between the hours of 11:30am - 12:30pm, the hot water temperature was tested throughout the facility and not measured within Title 22 Regulation guidelines. In the kitchen, it was measured at 128.2 degrees F. In bathroom #1, it was measured at 130.3 degrees F. In bathroom #2, it was measured at 131.6 degrees F.
  • While reviewing medications, at 12:21pm, the Assistant Administrator stated that Tylenol 500 MG Tablet (take 2 tablets, 1000 MG by mouth every 8 hours as needed) and Artificial Tears Drops 0.2-0.2-1 (instill 2 drops to both eyes three times a day for dry eyes) were discontinued as they were not being administered to Resident #1 (R1). There was no discontinue order in the file of R1 for the Tylenol 500 MG or the Artificial Tears Drops 0.2-0.2-1.
  • At 11:24am, LPA observed the wooden fence/gate located on the west side of the house, facing the street was in disrepair and would not open or close properly.

The following deficiencies were observed to be in violation under California Code of Regulations Title 22.
(refer to 809D).
An exit interview was conducted and a copy of this report was provided along with the appeals rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2022 01:42 PM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 04/12/2022 at 01:18 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: MONTANA VISTA
FACILITY NUMBER: 198601496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2022
Section Cited

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Furniture, Fixtures, Equipment, and Supplies.
Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
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This requirement is not met as evidenced by; Between the hours of 11:30am - 12:30pm, the hot water temperature was tested throughout the facility and not measured within Title 22 Regulation guidelines. In the kitchen, it was measured at 128.2 degrees F. In bathroom #1, it was measured at 130.3 degrees F. In bathroom #2, it was measured at 131.6 degrees F.
This poses an immediate health, safety risk to persons in care.
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Type A
04/13/2022
Section Cited

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Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement is not met as evidenced by;
While reviewing medications, at 12:21pm, the Assistant Administrator stated that Tylenol 500 MG Tablet (take 2 tablets, 1000 MG by mouth every 8 hours as needed) and Artificial Tears
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Drops 0.2-0.2-1 (instill 2 drops to both eyes three times a day for dry eyes) were discontinued as they were not being administered to Resident #1 (R1). There was no discontinue order in the file of R1 for the Tylenol 500 MG and the Artificial Tears Drops 0.2-0.2-1. This poses an immediate health, safety risk to persons in care.
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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:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2022 01:42 PM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 04/12/2022 at 01:34 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: MONTANA VISTA
FACILITY NUMBER: 198601496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2022
Section Cited

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Buildings and Grounds. The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by; At 11:24am, LPA observed the wooden fence/gate located on the west side of the house, facing the street was in disrepair and would
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not open or close properly.
This poses a potential health, safety risk to persons in care.
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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:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


LIC809 (FAS) - (06/04)
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