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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601500
Report Date: 02/20/2025
Date Signed: 02/20/2025 03:12:58 PM

Document Has Been Signed on 02/20/2025 03:12 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/
DIRECTOR:
JANA WESTFACILITY TYPE:
735
ADDRESS:550 MAR VISTA AVENUETELEPHONE:
(626) 584-6689
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY: 6CENSUS: 5DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:31 PM
MET WITH:Lillie Miles - Direct Support StaffTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst(LPA) Mary Flores conducted an unannounced annual visit using the CARE inspection tool. LPA met with Lillie Miles and explained the reason for the visit. Administrator arrived shortly after.

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 conducted a tour with Lillie Miles and observed the following:
Facility is in good repair indoor and outdoor. Living room/dining room were observed to have sufficient furniture. Kitchen was observed clean and in good repair. Sufficient supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Medication cabinet was locked, sharps are stored in staff's room. Cleaning supplies were observed under the sink inaccessible to the clients. Four client rooms were observed to have sufficient lighting, required furniture, and bedding supplies. Additional linens were observed stored. Two bathrooms were observed clean, in good repair, and water temperature was tested between 108.3 - 113.1 degrees F. which is within the required 105-120 degrees F. Smoke/Carbon monoxide detectors were tested and are in working condition. Fire extinguishers were observed. Front porch has a covered sitting area. No large bodies of water were observed. Passageways and stairways were observed clear of debris.

Medication, and files were reviewed for 5 clients. Four staff flies were reviewed.
Administrator certificate #6022230735 exp. date: 4/16/26 was observed. HIV/TB test was observed for administrator taken within the last two years.

(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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 2
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
VISIT DATE: 02/20/2025
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Infection Control Plan and Emergency Disaster Plan version were reviewed. Emergency Drill was last conducted on 2/21/25 and conducted quarterly.

No deficiencies were noted during this visit.

Exit interview was conducted with administrator and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
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