198601498-2-5-2026-28-AS-DKOI-DQZUE9-20260205143045

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601498
Report Date: 02/05/2026
Date Signed: 02/05/2026 02:32:15 PM

Document Has Been Signed on 02/05/2026 02:32 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ARROYO VISTA		FACILITY NUMBER:	198601498
ADMINISTRATOR/ DIRECTOR:	KIMBERLY ISAAC		FACILITY TYPE:	735
ADDRESS:	1661 KENILWORTH		TELEPHONE:	(626) 808-9751
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY: 6		CENSUS: 5	DATE:	02/05/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:38 AM
MET WITH:	Shequita Porter, Staff		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required-1 year visit. Upon arrival, no one answered the door and LPA called the facility number. At 9:45am, Shequita Porter, Staff arrived and explained the purpose of the visit. At 11:30am, Kimberly Isaac, 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 an Infection Control Plan in place. 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 and Disaster Drill was last conducted on 06/01/2025. Valid Liability Insurance and Surety Bond are 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. 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 12/08/2025. Knives, cleaning solutions, and disinfectants are locked in a cabinet and inaccessible to clients. There are no firearms or weapons stored at the facility. Fireplace is closed and inaccessible to clients.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/05/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARROYO VISTA	FACILITY NUMBER: 198601498
	VISIT DATE: 02/05/2026

NARRATIVE

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Physical Plant & Environment Safety [Cont.]: 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. Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. Hot water supply measured at 146.1 degrees F in bathroom #1 and 157.1 degrees F in bathroom #2.

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 are associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed four (4) staff files which include Personnel Record, First Aid/CPR/AED, Health clearance, TB clearance, Employee Rights, and Staff Training. Administrator’s Certificate expires on 08/30/2026. Administrator’s file has an updated HIV and TB training in file.

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 which includes the Face Sheet, the Admission Agreement, Medical Assessment, Physician’s Report, TB Clearance, Central Medication Destruction Records, Physician’s Orders, and Clients Personal Rights observed. However, LPA observed in Client #1 (C1), Client #4 (C4), and Client #5 (C5’s) file did not have physician's documentation for ambulatory status.

Food Service: The kitchen was inspected and the food preparation area and storage areas were observed to be clean and sanitary. There is sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. The food is properly stored in the refrigerator. There are no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas.

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.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/05/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARROYO VISTA	FACILITY NUMBER: 198601498
	VISIT DATE: 02/05/2026

NARRATIVE

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Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. Facility maintains documentation of the required emergency drills. Fire and Disaster Drill was conducted on 06/01/2025.

Emergency Intervention: No manual restraints or seclusion are used with clients in care.

$ 250.00 Civil Penalty is being issued during today's visit as a result of a repeat violation within a 12 month period ( 80088(e)(1) ). LIC421FC provided to the Administrator during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit will be documented on the LIC809-D. Exit interview was held and a copy of the report and appeal rights were provided to Administrator, Kimberly Isaac.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/05/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/05/2026 02:32 PM - It Cannot Be Edited

Created By: Daniel Konishi On 02/05/2026 at 01:03 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: 02/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(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
1 2 3 4	Based on observation, LPA Konishi measured client’s restroom #1 hot water temperature read at 146.1 degrees F and client’s restroom #2 hot water temperature read at 157.1 degrees F, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/06/2026
	Plan of Correction
1 2 3 4	Administrator shall immediately adjust water temperature. Administrator to check water temperature at various different times throughout the day and maintain and submit a water temperature log to the LPA for the next 3 days to ensure that hot water temperature falls within 105 degree F and 120 degrees F. Administrator will provide a copy of the log to the department once water temperature falls within Title 22 guidelines.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

	Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/05/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/05/2026 02:32 PM - It Cannot Be Edited

Created By: Daniel Konishi On 02/05/2026 at 01:03 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: 02/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80069(c)(4)

Client Medical Assessments

(c) The medical assessment shall include the following: (4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed in Client #1 (C1), Client #4 (C4), Client #5 (C5’s) file did not have physician's documentation for ambulatory status which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/19/2026
	Plan of Correction
1 2 3 4	Administrator will send Client #1 (C1), Client #4 (C4), Client #5 (C5’s) physician's documentation for ambulatory status to the LPA by the POC due date. Daniel.Konishi@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

	Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/05/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

LIC809 (FAS) - (06/04)

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