198602166-11-16-2022-28-AS-KRAZ-CL8M3F-20221116081501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602166
Report Date: 11/15/2022
Date Signed: 11/16/2022 08:15:35 AM

Document Has Been Signed on 11/16/2022 08:15 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:	SIESTA ASSISTED LIVING		FACILITY NUMBER:	198602166
ADMINISTRATOR:	MORENO, FRANCISCO		FACILITY TYPE:	740
ADDRESS:	163 N PASADENA AVENUE		TELEPHONE:	(626) 642-7409
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY:	6	CENSUS: 5	DATE:	11/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Administrator Francisco Moreno		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Francisco Moreno and explained the purpose of the visit. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected. There are 5 residents ages 60 and above. The facility has a Dementia waiver and a hospice waiver for 4 residents. The facility has (3) hospice resident in place. Administrator certificate expires 08/23/2023. OBSERVATIONS: LPA and Administrator toured the home and inspected (4) resident bedrooms, (2) bathrooms, kitchen, dining room, living room, and detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 and measured at 113.0 F which is within the required 105 - 120 degrees. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. Carbon Monoxide detectors are intertwined with the smoke detectors and operable. There is a fire extinguisher located in the kitchen which is fully charged. LPA observed sharps and knives to be stored a drawer however, the drawer key was misplaced. Administrator stated the drawer can be opened with any pointed tool. LPA observed a locked gated, which grants access to the kitchen; which was observed to be inaccessible to clients. Kitchen appliances are clean and were operating at the time of the visit. Cleaning supplies and toxins are locked in the garage and are inaccessible to residents. First Aid kit was fully stocked with current manual. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. *CONT on LIC809-C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SIESTA ASSISTED LIVING	FACILITY NUMBER: 198602166
	VISIT DATE: 11/15/2022

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Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed.
(5) out of the (5) resident medications were reviewed. Medications are centrally stored in a closet locate by the dining room. LPA observed medication for resident #1 (R1) did not match medication list. Administrator stated that R1 went to the doctors on 11-10-22 to receive a refill on an antibiotic. R1 was prescribed a new antibiotic. Upon return to the facility, R1's responsible party did not provide the facility with an updated medication list. LPA is granting Administrator (1) business day (11-16-22) to provide updated medication list. Failure to provide will result in deficiency
Staff files were reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC809 (FAS) - (06/04)

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