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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601602
Report Date: 06/09/2022
Date Signed: 06/09/2022 01:20:26 PM


Document Has Been Signed on 06/09/2022 01:20 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:MONTEVISTA GARDENFACILITY NUMBER:
198601602
ADMINISTRATOR:LAURA MARCELA AGUILARFACILITY TYPE:
740
ADDRESS:1812 MONTE VISTA ST.TELEPHONE:
(626) 568-2793
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 5DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Laura Aguilar - Assistant Administrator TIME COMPLETED:
01:45 PM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual inspection visit with focus on infection control domain, food and medication review. LPA Flores met with caregiver and explained the reason for the visit. Laura Aguilar Assistant Administrator arrived 5 minutes later.

The Facility is licensed to serve 6 non-ambulatory residents over the age of 60 and has an approved Hospice Waiver for six (6) residents. Facility is a single family home with 5 bedrooms, 3 bathrooms, a living room, dinning room, a kitchen, a front yard, a fenced back yard, a 5ft fenced pool, and a detached garage. Smoke/ Carbon monoxide detectors were tested and in working. Facility has auditory devices on exit doors.

LPA Flores tour the facility with Laura Aguilar and observed the following:
Living room has a fireplace with a metal screen cover. 5 bedrooms were observed with all required furniture, sufficient lighting, and all required bedding items. LPA observed 3 bathrooms which had the required grab bars, and skid mats, water temperature was tested in bathroom #1 at 114.3; bathroom #2 at 116.3; and bathroom #3 at 115.4 which is within the required water temperature of 105 - 120 degrees F. Facility's kitchen was observed to have sufficient food supplies of at least 2 days of perishables and 7 days of non-perishables. Sharps and cleaning supplies were locked under the kitchen sink. Medication was observed locked in a cabinet by the kitchen, LPA reviewed medication and files for 3 residents and 3 staff files. Administrator's certificate #6020261740 was reviewed for Luis Aguilar and expires in 9/23/22.
Facility is following all infection control guidelines.

No deficiencies were cited during this visit.

Exit interview was conducted with Laura Aguilar Assistant Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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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