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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601682
Report Date: 11/13/2022
Date Signed: 11/13/2022 04:08:17 PM

Document Has Been Signed on 11/13/2022 04:08 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ARIEL VISION ARFFACILITY NUMBER:
198601682
ADMINISTRATOR:OROSZ, TAMIFACILITY TYPE:
735
ADDRESS:2611 W. 181ST STREETTELEPHONE:
(310) 327-5949
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 4CENSUS: 4DATE:
11/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Martha Amparo DSPTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced Annual inspection visit and infection control inspection to the above facility. LPA was met by Martha Amparo DSP, and the purpose of today’s visit was explained.

There are currently (4) Harbor, Regional Center consumers in placement. All (4) clients are ambulatory. (0) non-ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 2 bathrooms, family room/office, living room, kitchen, dining room, shaded area, indoor and outdoor activity area, laundry room and a detached garage.

LPA and Martha Amparo DSP) toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms 1-4 are occupied by clients and contain the mandated furniture. The (2) bathrooms are clean and operational. Smoke detectors and carbon monoxide detector comply and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. 1 staff file is current, 1 resident file is current along with medications. The water temperature is at 118 degrees. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and/or items are inaccessible to clients, (2) fire extinguishers are fully charged. First Aid kit complete and with manual. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ARIEL VISION ARF
FACILITY NUMBER: 198601682
VISIT DATE: 11/13/2022
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The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & IPAD for residents to use, resident’s temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPE's are enough for 30 days. All clients and staff are vaccinated and boosted.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Martha Amparo DSP and copy of report provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2022
LIC809 (FAS) - (06/04)
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