<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601499
Report Date: 04/28/2022
Date Signed: 04/28/2022 11:07:58 AM

Document Has Been Signed on 04/28/2022 11:07 AM - 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:SIERRA VISTAFACILITY NUMBER:
198601499
ADMINISTRATOR:KIMBERLY ISAACFACILITY TYPE:
735
ADDRESS:670 W. HOWARD STREETTELEPHONE:
(626) 398-1530
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 4DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Latrina Brown, DSPTIME COMPLETED:
11:20 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst's (LPA's) Vasallo and Pena conducted an annual required visit. LPA's met with staff member, Latrina Brown and explained the reason for the visit. Administrator, Nancy Parker was notified via phone of the visit. Administrator was attending required training and was not available for the visit. Administrator also indicated the personnel files were not at the facility and most of the clients records were also not at the facility. LPA's used the infection control tool to evaluate the facility. LPA's observed the physical plant, COVID-19 procedures, reviewed clients' medications and records and observed food supply, The facility cares for adults with developmental disabilities.

All client bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. Both client bathrooms were toured and the hot water was 116.2 degrees which is within the required 105 - 120 degrees. There were no toxic chemicals accessible to clients. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the living room and dining area. These areas are clean and have the required furniture. There is a screening station at the entrance of the home which has PPEs and a thermometer to screen visitors. Staff document client temperatures daily and require visitors to sign in. Facility currently has at least a 30-day supply of PPEs.

LPA's could not verify client's emergency contact is updated since client files were unavailable. Infection control training for staff could not be verified since staff files were not available for review at the time of the visit. A staff roster was reviewed and fingerprint clearances were confirmed. LPA's reviewed 4 clients' medications. Medications are documented properly and given as prescribed.

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.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 04/28/2022 11:07 AM - It Cannot Be Edited


Created By: Tony Vasallo On 04/28/2022 at 10:51 AM
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: SIERRA VISTA
FACILITY NUMBER: 198601499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)(5)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (5) Recognition of early signs of illness and the need for professional assistance.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interviews, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Facility did not have proof of staff training on infection prevention, symptoms, transmission and PPE.
POC Due Date: 05/12/2022
Plan of Correction
1
2
3
4
Facility will submit proof of infection control training by POC due date 5/12/22.
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.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3