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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601500
Report Date: 02/27/2023
Date Signed: 02/27/2023 01:16:21 PM


Document Has Been Signed on 02/27/2023 01:16 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: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:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Jana West - Administrator TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst(LPA) Mary Flores conducted an unannounced annual visit with focus on the infection control domain, medication, and food review. LPA met with Jana West Administrator and explained 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.

LPA Flores conducted a tour of the home with Jana West Administrator and observed the following:
Facility is clean and in good repair. Screening station is located by the entrance. Signs are posted in the dining room, and in the bathrooms. Water temperature was tested in bathrooms as follow: bathroom #1 water temperature tested at 123.8 degrees F. and bathroom #2 water temperature tested at 113.0 degrees F. which is not within the required 105-120 degrees F. Medication and cleaning supplies were observed locked in the kitchen. Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. All client rooms were observed in good repair and with sufficient lighting, furniture, and bedding supplies. No large bodies of water observed. Smoke detectors were tested and in working condition. Last fire drill was conducted on 9/19/22. Fire extinguisher was observed, last checked on 10/15/22. Medication was reviewed for 5 clients and Administrator certificate was observed for Jana West #6022230735 exp date: 4/16/24.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Jana West - Administrator and a copy of this report, LIC 809D, technical advisory, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
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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Document Has Been Signed on 02/27/2023 01:16 PM - It Cannot Be Edited

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: MAR VISTA MANOR
FACILITY NUMBER: 198601500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 bathroom #1 water temperature tested at 123.8 degrees F.,which is not within the required 105-120 degrees F.,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2023
Plan of Correction
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Licensee will ensure water temperature is maintain within the required 105-120 degrees F., at all times and will certify on LIC 9098 by POC due date 2/28/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
LIC809 (FAS) - (06/04)
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