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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601498
Report Date: 05/18/2023
Date Signed: 05/18/2023 03:39:06 PM

Document Has Been Signed on 05/18/2023 03:39 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:
05/18/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced Annual visit using the Care Tool. LPA arrived unannounced and upon arrival no staff/clients were present at the facility. LPA called Administrator Kimberly Isaac and had Assistant Administrator Jana West met LPA 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 with Jana West. Currently, there are six (6) clients in placement , 5 present and 1 in rehabilitation.This is a single story home consisting of: three (3) client bedrooms, two (2) bathrooms, living room, dinning room, kitchen, laundry area, outside patio and a detached garage. There is a storage unit/shed and garage 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.

All required posters were posted and LPA observed PPE. LPA observed client bedrooms which had adequate furniture. Smoke detector / carbon monoxide was tested and were operable. Fire extinguisher charged and serviced. Last Fire/Disaster Drill: 3-3-2023. LPA observed in hallway closet obtaining towels,bed sheets, and linen. Bathrooms have the required hygiene items, grab bars and non-skid mat. The hot water temperature was tested and was measured within Title 22 Regulation, measuring at 108 F throughout the facility. The kitchen was inspected, sharps were locked. There is sufficient perishable and non-perishable food for clients in care. All the appliances are clean and working properly.

LPA with Kimberly Isaac observed the centrally stored medication area to be locked and inaccessible to clients. LPA reviewed clients' medications and observed a deficiency on one (1) clients' medication, 3 medication tablets were not provided on 5/16/23, see 809D. LPA reviewed (5) staff and (6) client files no deficiencies were observed. Staff are cleared and staff/clients have appropriate paperwork filed.The first aid kit was observed and found to be in compliance with the Title 22 Regulations locked in cabinet.

Continuation on 809C...

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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: ARROYO VISTA
FACILITY NUMBER: 198601498
VISIT DATE: 05/18/2023
NARRATIVE
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Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D. Exit interview held. A copy of the report(s)and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/18/2023 03:39 PM - It Cannot Be Edited


Created By: Ashley Calderon On 05/18/2023 at 02:58 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: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
80075(b)(5)(B)
Health Related Services- Medications shall be given according to physicians directions.

This requirement is not met as evidenced by:

LPA Calderon observed at 12:50pm, that client was not provided three evening medications. LPA observed pill remaining in bubble pack for date 5/16/23. Medication Clonazepam 0.5mg, Risperidone 3mg, Benztropine Mes 2 mg were not given to client.
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. 1 out of 5 clients in care, poses to an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2023
Plan of Correction
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Licensee during LPA's visit sent a incident report and called pharmacy regarding medication error on how to comply with physicians' order. Licensee shall have a in service training in regards to medication administartion, medication review, reading/ using medication record and following doctors orders. Licensee will in additionally use training company (Relias) or have a medical professional provide training.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023


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