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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601602
Report Date: 07/11/2023
Date Signed: 07/11/2023 11:35:08 AM


Document Has Been Signed on 07/11/2023 11:35 AM - 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: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: 4DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:14 AM
MET WITH:Laura Aguilar - AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst(s) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Laura Aguilar Administrator and explained the reason for the visit.

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.

LPA Flores conducted a tour of the facility with administrator and observed the following:
Facility is clean and in good repair inside and outside. Smoke/ Carbon monoxide detectors were tested and in working condition. Facility has auditory devices on exit doors. Backyard has a 5ft fence and a covered sitting area. Living room has a covered fireplace. Cleaning supplies are stored under the kitchen's sink and locked. Refrigerator is maintained at 33 degrees F., freezer at -3 degrees F., and meets requirements. Sufficient food was observed stored for at least 2 days of perishables and 7 days of non-perishables. Five (5) resident rooms were observed with sufficient bedding/lighting and required furniture. Three (3) bathrooms were observed with grab bars, skid mats, and water temperature was tested. Water temperature measured between 109.1 - 110.5 degrees F., which is within the required 105-120 degrees F. Fire extinguishers were last checked on 4/15/22. Backyard provides a shaded sitting area and a has a 5ft fence around the pool. Laundry is in the basement. Detached garage is used as storage and PPE supplies, emergency food supplies, and additional food was observed.

LPA Flores reviewed files and medication for 4 residents and 5 staff files. Administrator certificate was observed for Luis Aguilar #6020261740 exp: 9/23/24.

No deficiencies were noted during this visit.
Exit interview was conducted with Laura Aguilar administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
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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