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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601499
Report Date: 02/21/2025
Date Signed: 02/21/2025 02:49:59 PM

Document Has Been Signed on 02/21/2025 02:49 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:SIERRA VISTAFACILITY NUMBER:
198601499
ADMINISTRATOR/
DIRECTOR:		KIMBERLY ISAACFACILITY TYPE:
735
ADDRESS:670 W. HOWARD STREETTELEPHONE:
(626) 398-1530
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 5DATE:
02/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:11 PM
MET WITH:Nancy Parker - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA met with Mario Findlay Reid, Direct Support Professional II (DSP II) and explained the purpose of the visit. At 12:19pm, Nancy Parker, Administrator arrived and assisted LPA. The facility is licensed to care for (6) developmentally disabled adults, ages 18 through 59, ambulatory only. All clients residing at this facility receive case management services provided by Frank D. Lanterman Regional Center.

LPA along with the Administrator inspected the facility using the Compliance and Regulatory Enforcement (CARE) tool and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Staff are adhering to infection control requirements. The facility has submitted the Infection Control Plan.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan was submitted to CCL and added to the Plan of Operation. Per Administrator, Surety Bond insurance is valid in the amount $5000 and will send proof of validity to LPA via email. Fire/Disaster Drill was last conducted on 01/18/2025.
Physical Plant/Environment Safety: The facility is a single-story home located in a residential area in Pasadena, Ca. A tour of the facility includes: living room, dining room, kitchen, 3 bedrooms, 2 bathrooms, attached garage, front yard and back yard. Currently, there are (5) clients living in the facility. Facility is a Level 4. The interior and exterior physical plant was inspected. Client bedrooms were toured. Bathroom has non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and observed shaded area with patio furniture. Kitchen knives, sharps objects and toxins are kept locked in a kitchen cabinet and inaccessible to clients. Smoke alarms and carbon monoxide were tested and operable. There fire extinguisher was observed and is fully charged. There are no firearms or weapons stored at the facility. Water temperature reading in bathroom #1 was 118.7 deg F and 119.1 deg F in bathroom #2 which are within the required 105-120 degrees Fahrenheit. *****CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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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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: SIERRA VISTA
FACILITY NUMBER: 198601499
VISIT DATE: 02/21/2025
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Staffing: A total of (13) staff including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared and have training.
Personnel Records/Staff Training: Reviewed files for (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator's certificate is valid and will expire on 12/14/2025.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Client rights posters and reporting posters are displayed within the facility.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. There are zero (0) client with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas.
Client Records-Incident Reports: LPA reviewed (3) client files. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Client Personal Property and Clients Personal Rights observed.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for (5) clients to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.
Incidental Medical Services: Per the Administrator, there is no client 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.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Technical assistance is issued.

Exit interview was held and a copy of the report was given to Administrator Nancy Parker.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC809 (FAS) - (06/04)
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