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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601500
Report Date: 02/20/2024
Date Signed: 02/20/2024 12:03:48 PM

Document Has Been Signed on 02/20/2024 12:03 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:
02/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Anita Savage - StaffTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores and Christian Gutierrez conducted an unannounced annual visit using the CARE inspection tool. LPAs met with Anita Savage 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.

LPAs conducted a tour with Anita Savage and observed the following:
Living room/dining room have sufficient furniture and in good repair. Kitchen was observed clean and in good repair. Sufficient supplies were observed for at least 7 days of perishables and 2 days of non-perishables. Medication cabinet was locked, sharps are stored in medication cabinet. Cleaning supplies were observed under the sink accessible to the clients. Each client room (4) has sufficient lighting, required furniture, and bedding supplies. Bathrooms (2) were observed clean, in good repair, and water temperature was tested between 124.7-129.2 degrees F. which is not within the required 105-120 degrees F. Linen cabinet was observed. Smoke/Carbon monoxide detectors were tested and in room #4 they were not working. Fire extinguishers were observed and last checked on 11/30/23. Front porch has a covered sitting area. No large bodies of water were observed.
Medication, files and P&I were reviewed for 5 clients. (3) staff flies were reviewed. Administrator certificate #6022230735 exp. date: 4/16/24 was observed. Infection Control Plan was reviewed, Emergency Disaster Plan version (10/03) was reviewed. Emergency Drill was last conducted on 1/11/24.
Deficiencies are noted on LIC 809D per Title 22 Regulations.
Exit interview was conducted with Jana West and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2024
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 6
Document Has Been Signed on 02/20/2024 12:03 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/20/2024 at 11:24 AM
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: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
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.

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 under the sink with cleaning and disinfecting solutions was observed unlock during the visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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Administrator will provide training to staff regarding section 80087 and maintaining cleaning solutions inaccessible to the clients by POC due date 2/21/24.
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 water temperature in bathroom #1(downstairs) tested at 124.7 degrees F., and bathroom #2 (upstairs) tested at 129.2 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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Administrator adjusted water temperature during the visit and will maintain a temperature log for the next seven days and will submit by 2/28/24.
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 Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/20/2024 12:03 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/20/2024 at 11:24 AM
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: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in administrator's HIV/TB training was not on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2024
Plan of Correction
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Administrator will obtain training and will submit a copy of certificate to the department by POC due date 2/27/24.
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

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 Emergency Disaster Plan reviewed during the visit was version (10/03) and not updated to version (12/21) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2024
Plan of Correction
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Administrator provided a copy of Emergency Disaster Plan version (12/21) at the end of the visit. Deficiency has been cleared during the visit.
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 Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024


LIC809 (FAS) - (06/04)
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