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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601500
Report Date: 03/05/2024
Date Signed: 03/05/2024 01:35:02 PM

Document Has Been Signed on 03/05/2024 01:35 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:
03/05/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Anita Savage - StaffTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction (POC) visit at the facility regarding deficiencies noted on 2/20/24. LPA met with Anita Savage and explained the reason for the visit.

On 2/20/24 LPA Flores conducted an unannounced annual visit and noted the following deficiencies:
Section CCR 80087(g) - Building and Grounds - During the visit on 2/20/24 LPA observed cabinet under the sink with cleaning and disinfecting solutions unlocked. 3/5/24 LPA observed cabinet locked at the time of the visit. Deficiency cleared as of 3/5/24.

Section CCR 80088(e)(1) - Fixtures, Furniture, Equipment, and Supplies - During the visit on 2/20/24 LPA tested water temperature in bathroom #1(downstairs) tested at 124.7 degrees F., and bathroom #2 (upstairs) tested at 129.2 degrees F. 3/5/24 LPA tested water temperature in both bathrooms and tested at 115.1 degrees F., which is within the required temperature. Deficiency cleared as of 3/5/24.

Section CCR 85064(k) - Administrator Qualifications and Duties - During the visit on 2/20/24 during file review administrator's HIV/TB training was not on file. On 3/5/24 certificated for HIV/TB taken on 4/28/23 was observed. Deficiency cleared as of 3/5/24.

Exit interview was conducted with Jana West and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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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