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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602166
Report Date: 09/07/2023
Date Signed: 09/07/2023 02:56:08 PM


Document Has Been Signed on 09/07/2023 02:56 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) 642-7409
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:6CENSUS: 4DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Francisco MorenoTIME COMPLETED:
03:00 PM
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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 and staff Krissia Mazariego. 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 2023.
The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in a closet located in the hallway. There were four (4) bedrooms designated for residents' use. All rooms were properly furnished with appropriate beddings and linens with sufficient lighting. There is also a sufficient supply of linen and towels stored in the linen closet. There are two (2) bathrooms at the facility. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured, and it ranged between 115-117 degrees Fahrenheit. Grab bars and non-slip mats were observed in both bathroom bathing areas. 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. LPA observed shaded seating areas in a back and front of the house. No large bodies of water were observed. LPA reviewed residents records and staff records. Medications were observed locked in the closet near kitchen and living room area and inaccessible to residents.

There are no deficiencies to report. Exit interview was conducted, appeal rights discussed, and a copy of the signed report was given to the Administrator.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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