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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601500
Report Date: 02/15/2022
Date Signed: 02/15/2022 03:27:26 PM

Document Has Been Signed on 02/15/2022 03:27 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:MAR VISTA MANORFACILITY NUMBER:
198601500
ADMINISTRATOR:JANA WESTFACILITY TYPE:
735
ADDRESS:550 MAR VISTA AVENUETELEPHONE:
(626) 584-6689
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY: 6CENSUS: 5DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Jana West - AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control domain, food and medication review. LPA Flores met with Jana West administrator and explain the reason for the visit.
The facility is licensed for 6 Ambulatory Developmentally Disabled clients between the ages of 18-59. The facility is vendor through Frank D. Lanterman Regional Center as a level 3 home. Facility is a two story residential house with (4) client bedrooms, (2) bathrooms, staff room, living room, dining room, kitchen, front covered porch patio, back yard, laundry room, office, and storage room. No large bodies of water observed. Smoke detectors were tested and in working condition. Last fire drill was conducted on 12/6/21

LPA Flores conducted a tour of the facility with Jana West administrator and observed the following:
Living room and dinning are furnished and have sufficient lighting. No screening area upon entrance to the facility. Kitchen cabinet with medication was observed unlocked. Food supplies were observed sufficient for 2 days of perishables and 7 days of non-perishables. Cabinet with cleaning solutions was observed unlocked and left top hinge was missing screws. Bathroom #1's(B1) water temperature was tested at 132.5 degrees F. and bathroom #2(B2) water temperature was tested at 133.2 degrees F. which is not within the required 105 -120 degrees F. No paper towels or hand-washing sign were observed. All bedrooms have the required furniture, bedding, and sufficient lighting throughout the facility. Porch was observed to have a couch and covered outside sitting area. LPA reviewed medication for client #1(C1), and #2(C2) and files for C1, C2, and staff #1(S1) and #2(S2). Administrator's certification was observed #6022230735 and expires on 4/16/22. Facility keeps screening log for staff and residents. Staff have not been fit tested for N95. Signs were not observed throughout the facility. No emergency contact numbers observed.

Deficiencies have been noted on LIC 809D, a technical violation, and technical advisories have been provided.
Exit interview was conducted with Jana West administrator and a copy of this report, LIC 809D, technical violation/ advisories, and appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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 12
Document Has Been Signed on 02/15/2022 03:27 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/15/2022 at 02:41 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: MAR VISTA MANOR
FACILITY NUMBER: 198601500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 cabinet with cleaning chemical solutions unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2022
Plan of Correction
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Administrator will ensure that chemical solution cabinet is locked at all times, will provide in-service training to staff and submit a photo, copies of sign in sheet and agenda to the department by 2/16/22.
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 B1 water tested at 132.5 degrees F and B2 water tested at 133.2 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2022
Plan of Correction
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Licensee will ensure to maintain water temperature within the required 105 - 120 degrees F and certify in LIC 9098 by 2/16/22 and will maintain a 7 day log to be submitted to the departmetn by 2/22/22.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022


LIC809 (FAS) - (06/04)
Page: 2 of 12
Document Has Been Signed on 02/15/2022 03:27 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/15/2022 at 02:41 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: MAR VISTA MANOR
FACILITY NUMBER: 198601500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 medication cabinet located in the kitchen was not locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2022
Plan of Correction
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Administrator will ensure that cabinet is locked at all times, provided an in-service training and submit a photo, copies of agenda and sign in sheet by 2/16/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022


LIC809 (FAS) - (06/04)
Page: 3 of 12