<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602166
Report Date: 09/09/2024
Date Signed: 09/09/2024 04:47:39 PM


Document Has Been Signed on 09/09/2024 04:47 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:SIESTA ASSISTED LIVINGFACILITY NUMBER:
198602166
ADMINISTRATOR:MORENO, FRANCISCOFACILITY TYPE:
740
ADDRESS:163 N PASADENA AVENUETELEPHONE:
(626) 804-3399
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:6CENSUS: 4DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Francisco MorenoTIME COMPLETED:
05:00 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
On 9/07/23 Licensing Program Analyst (LPA) Nune Margaryan conducted an Annual Required visit and inspection of the facility. LPA met with the Administrator, Francisco Moreno. LPA explained the purpose of the visit. With the assistance of Administrator, LPA took a tour of the physical plant.

Required postings were observed in the facility. Carbon monoxide detectors are present at the facility and residents bedrooms. They are tested and were operational during the visit. Fire extinguisher is located in the kitchen and were last serviced on February 2024. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked and are inaccessible to residents. LPA observed plenty linens, towels in the linen closet in the dining room. Fire extinguisher observed in the facility fully charged. Fire drill was conducted on 07/01/24.
There were four (4) bedrooms designated for residents' use. All rooms were properly furnished with appropriate beddings and linens with sufficient lighting. There are two (2) bathrooms at the facility ( 1 for staff and 1 for residents). The hot water temperature was tested and was measured within Title 22 Regulation guidelines. Grab bar and non-slip mat was observed in the bathroom bathing area. Common areas included the living room and dining area were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Facility wall thermostat was set at 76.0°F and observed to be within the required range. LPA observed detached garage/ storage room. Laundry located in the garage. There is second refrigerator in the garage. Garage/Storage door is locked. The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. LPA observed shaded seating areas in the front of the house. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed clients and staff files. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

No deficiency was observed during today's visit. Exit interview was conducted and a copy of report was provided to Administrator.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
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 1