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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601500
Report Date: 03/01/2022
Date Signed: 03/01/2022 02:06:34 PM

Document Has Been Signed on 03/01/2022 02:06 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:
03/01/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Kimberly Isaac - Assistant Administrator TIME COMPLETED:
02:00 PM
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Licensing Program Analyst(s) LPA Mary Flores conducted a plan of correction (POC) visit at the facility to follow up on deficiencies given during annual visit on 2/15/22. LPA Flores met with Kimberly Isaac assistant administrator and explained the reason for the visit.

On 2/15/22 during an annual visit LPA Flores gave the following deficiencies:
Section 80087(g)(1) Building and Grounds - cleaning solutions were observed unlocked in kitchen cabinet. On 3/1/22 LPA Flores observed cabinet with lock and staff opened cabinet to utilized supplies.

Section 80088(e)(1) Fixtures, Furniture, Equipment, and Supplies - water temperature in bathroom #1 was tested at 132.5 degrees F and in bathroom #2 tested at 133.2 degrees F which is not within the required 105-120 degrees F. On 3/1/22 LPA Flores tested water temperature in bathroom #1 at 117.3 degrees F and bathroom #2 at 119.9 degrees F which is within the required105 -120 degrees F.

Section 80075(k)(1) Health-Related Services - medication cabinet located in kitchen was observed unlocked during the visit. On 3/1/22 LPA Flores observed cabinet locked during the visit.

Deficiencies have been cleared during this visit.

Exit interview was conducted with Kimberly Isaac Assistant Administrator and a copy of this report was provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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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