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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601499
Report Date: 03/23/2023
Date Signed: 03/23/2023 03:29:47 PM

Document Has Been Signed on 03/23/2023 03:29 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:SIERRA VISTAFACILITY NUMBER:
198601499
ADMINISTRATOR:KIMBERLY ISAACFACILITY TYPE:
735
ADDRESS:670 W. HOWARD STREETTELEPHONE:
(626) 398-1530
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 3DATE:
03/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:DSP- Latrina BrownTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Ashley Calderon and Erike made and unannounced visit to conduct the Annual inspection focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. Upon arrival LPAs met with DSP worker Latrina Brown.

LPA Calderon and Zaragoza along side with Ms.Brown used Care Tools and conducted a tour of the facility. Tour consisted of living room, kitchen, dining room, 2 bathrooms, 3 client bedrooms, backyard and attached garage.

LPA Calderon interviewed (3) clients, (1) staff interviews, 1 staff present at the facility at the time of visit.

The following was conducted and inspected:
  • Outdoor and indoor passageways are free of obstruction.
  • Bathrooms were operable.
  • Hot water measured between Title 22 regulations, read 114.7 F.
  • Smoke detectors and carbon monoxide were tested and operable.
  • Required postings observed.
  • Fire extinguisher located in kitchen, fully charged and serviced.
  • Sufficient supply of extra linen and towels stored inside the hallway cabinets.
  • Personal hygiene supplies located in kitchen cabinet.
  • Facility temperature for clients was maintained at comfortable temperature.
  • Washer/Dryer appliances observed in garage.
  • Backyard has shaded area for clients, no large bodies of water was observed.
  • PPE was observed at the front entrance.
(Continuation on 809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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: SIERRA VISTA
FACILITY NUMBER: 198601499
VISIT DATE: 03/23/2023
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KITCHEN:
  • Freezers/refrigerators appear sanitary and temperature maintained.
  • Sufficient non-perishable and perishable food items for clients in care located in kitchen.
  • Emergency food and bags are located in garage.
  • Canned goods stored in kitchen.
  • Sharps are locked inaccessible to clients.

BEDROOMS:
  • Rooms had required furnishing and in good condition.
  • Beds have the required linen/supplies.

MEDICATION:
  • Medications are stored, locked and inaccessible to clients, located in kitchen cabinet.
  • Medication and First Aid Kit/ Manual was reviewed.
  • LPA Calderon reviewed (5) client medications and Medication Log. Medications given as prescribed and documented properly.

RECORD REVIEW:
LPA Calderon reviewed Client files.
  • (5) Client file reviewed, no deficiencies.
  • (4) Staff files will be reviewed as LPA requested to be sent to LPA via email from Administrator who was not present during the visit.

Care Tool was completed and based on Title 22 Regulations, no deficiencies cited per California Code of Regulations, Title 22, Division 6.

An exit interview was conducted with DSP worker Latrina Brown and a copy of today's reports were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC809 (FAS) - (06/04)
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