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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 02:07:08 PM

Document Has Been Signed on 03/01/2022 02:07 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:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kimberly Isaac - Assistant Administrator TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst(s) LPA Flores conducted a case management COVID 19 visit during a plan of correction visit (POC). LPA Flores met with Kimberly Isaac Assistant Administrator and explained the reason for the visit.

On 3/1/22 during POC visit LPA Flores did not observed a screening area upon entrance to the facility. Staff took LPA's temperature and upon walking to the dining room staff provided a signing sheet with date, name, reason for visiting, and signature. LPA Flores asked if there was an additional signing sheet and staff stated "no". No screening questions or temperature log was observed for visitors. LPA Flores did not observed paper towels in bathroom #2.

During the annual visit on 2/15/22 facility was provided technical advisories regarding infection control recommendations and guidelines.

Deficiencies are noted on LIC 809D under Title 22 Division 6 Chapter 1.

Exit interview was conducted with Kimberly Isaac Assistant administrator and a copy of this report, LIC 809D,and appeal rights have been 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)
Page: 1 of 2
Document Has Been Signed on 03/01/2022 02:07 PM - It Cannot Be Edited


Created By: Mary G Flores On 03/01/2022 at 01:51 PM
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: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2022
Section Cited
CCR
80072(a)(2)

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80072 Personal Rights: (a)... each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidence by:
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Administrator will ensure that infection control guidelines are in place at all times, will provided in-service training regarding current guidelines and will submit to the department a copy of signing sheet, and agenda by 3/8/22.
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Based on observation licensee did not ensure that facility follows infection control protocols by screening and providing a screening area before entering the facility, and paper towels in bathroom #2 which poses a potential safety, health, personal rights risk to persons in care.
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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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


LIC809 (FAS) - (06/04)
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