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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601498
Report Date: 03/18/2022
Date Signed: 03/18/2022 12:52:35 PM

Document Has Been Signed on 03/18/2022 12:52 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:ARROYO VISTAFACILITY NUMBER:
198601498
ADMINISTRATOR:KIMBERLY ISAACFACILITY TYPE:
735
ADDRESS:1661 KENILWORTHTELEPHONE:
(626) 808-9751
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 6DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Staff Rochelle Sisco and
Assistant Administrator Jana West		TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Annual visit using the infection Control Evaluation Tool. LPA arrived unannounced and met with staff Rochelle Sisco. The purpose of the inspection was discussed. The Assistant Administrator Jana West arrived shortly after to assist with the visit. The facility is licensed to serve six (6) developmentally disabled adults between the ages of 18-59.
LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed staff and resident files. Currently, there are six (6) clients in placement .LPA observed two (2) clients at the time of this visit.

This is a single story home consisting of: three (3) client bedrooms, two (2) bathrooms, living room, dinning room, kitchen, laundry area, outside patio / activity area and detached garage. There is a storage unit/shed in the back yard which is kept locked and inaccessible to clients. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways were 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 during this visit.

Client bedrooms were checked. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. The client bathrooms were toured. Bathrooms have the required hygiene items, grab bars and non-skid mat. The hot water temperature was tested and was not measured within Title 22 Regulation guidelines. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. LPA observed laundry detergent unlocked and accessible to clients in the laundry area near the kitchen.

Continue 8089C




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SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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: ARROYO VISTA
FACILITY NUMBER: 198601498
VISIT DATE: 03/18/2022
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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. The carbon monoxide detectors were working properly, fire extinguisher was fully charged and operational.

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 to Assistant Administrator.

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

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
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Document Has Been Signed on 03/18/2022 12:52 PM - It Cannot Be Edited


Created By: Nune Margaryan On 03/18/2022 at 12:21 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: ARROYO VISTA
FACILITY NUMBER: 198601498

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture Equipment and Supplies. Hot water delivered to fixtures used by clients shall 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).


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 in. Water temperature was measured at 140.1 degrees F in the bathrooms, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
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Citation was cleared at the time of visit. No further action is needed.
Type A
Section Cited
CCR
8087(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 observation, the licensee did not comply with the section cited above. Laundry detergent observed in the laundry area and was accessible to clients at the time of this visit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
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Citation was cleared at the time of visit. No further action is needed.
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: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


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