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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601498
Report Date: 04/10/2025
Date Signed: 04/10/2025 04:21:46 PM

Document Has Been Signed on 04/10/2025 04:21 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:ARROYO VISTAFACILITY NUMBER:
198601498
ADMINISTRATOR/
DIRECTOR:		KIMBERLY ISAACFACILITY TYPE:
735
ADDRESS:1661 KENILWORTHTELEPHONE:
(626) 808-9751
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 5DATE:
04/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Jana West - Co-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Rochelle Sisco, DSP II and explained the purpose of today's visit. At 2:05pm, Jana West, Co-Administrator arrived and assisted LPA with the inspection. The facility is approved for (6) developmentally disabled clients ages 18-59, (5) ambulatory and (1) non ambulatory. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility has submitted the Infection Control Plan Staff are adhering to infection control requirements.
Operational Requirements: A current Plan of Operation was reviewed. A fire clearance is in place. The last Fire Drill was last conducted on 02/22/2025. Surety Bond is in place.
Physical Plant & Environment Safety: This facility is a single story home consists of kitchen, dining room, living room, (3) client bedrooms, (2) bathrooms, laundry area, detached garage, backyard and a shaded patio with seating. Currently, there are (5) clients residing in the home. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Smoke alarms and carbon monoxide were tested and operable. Laundry area is next to the kitchen. The fire extinguisher near the kitchen was serviced on 02/24/2025. Knives, cleaning solutions, and disinfectants are locked in a cabinet and inaccessible to clients. There are no firearms or weapons stored at the facility. Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. Hot water supply measured at 125.6 deg F (bathroom #1) and 128 deg F (bathroom #2) even after checking it 3x. Additionally, the sink in bathroom #1 was clogged, not draining properly. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. *****Refer to LIC 809C for the continuation of this report.*****
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: ARROYO VISTA
FACILITY NUMBER: 198601498
VISIT DATE: 04/10/2025
NARRATIVE
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Staffing: A total of eleven (11) staff members including the Administrator provide care and supervision to the client. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Administrator certificate expired in August 2024 and renewal was sent on 07/26/2024. Administrator provided proof that application was pending.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed (4) staff files. Proof of staff training, health clearance, and vaccinations are current.
Client Rights-Information: Client personal rights are posted. Facility provides internet service and phone to the client.
Client Records-Incident Reports: LPA reviewed (5) client files. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), IPP, Consent For Medical Treatment, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Food Service: There is sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. There are no clients with special diets residing at this facility. LPA observed that food items such as canned coffee, macaroni and cheese, bottled water and variety of chips stored in a locked cabinet along with pesticides and cleaning supplies.
Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for all (5) clients. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.
Incidental Medical Services: There are no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D and Technical Violation issued. Exit interview, appeals rights and a copy of this report was provided to Jana West, Co-Administrator.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/10/2025 04:21 PM - It Cannot Be Edited


Created By: Bennette Pena On 04/10/2025 at 02:57 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: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) 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).

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 that water temperature reading in bathroom #1 & bathroom #2 measured at 125.6 deg F (bathroom #1) and 128 deg F (bathroom #2) even after checking it 3x which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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Administrator shall ensure that hot water temperature shall be maintained between 105-120 deg F at all times. Administrator to send hot water reading daily log for 7 days starting tomorrow, 04/11/2025 and submit to CCL/LPA.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/10/2025 04:21 PM - It Cannot Be Edited


Created By: Bennette Pena On 04/10/2025 at 02:57 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: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(16)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (16) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

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 that food supplies such as canned coffee, macaroni and cheese, bottled water and variety of chips stored in a locked cabinet along with presticides and cleaning supplies which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 04/16/2025
Plan of Correction
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Administrator will send pictures of the cabinet/storage areas showing that food supplies are stored separately from pesticides/cleaning supplies. Pictures to be sent to CCL/LPA by POC due date.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
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