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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602623
Report Date: 10/24/2022
Date Signed: 10/24/2022 01:22:32 PM


Document Has Been Signed on 10/24/2022 01:22 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:VISTA DEL MAR VILLASFACILITY NUMBER:
198602623
ADMINISTRATOR:CHEN, DERICKFACILITY TYPE:
740
ADDRESS:3049 EAST DEL MAR BLVDTELEPHONE:
(626) 215-1045
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 3DATE:
10/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Cristina Chen - Assistant Administrator TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted a case management visit regarding deficiencies observed during pre-licensing conducted on 10/24/22.

LPA observed the following deficiencies:
During file review LPA observed physician's report note Resident #2(R2) and #3(R3) as bedridden. Facility is licensed to served 1 bedridden resident. During this visit facility contacted Fire Department and notify that there are currently 2 bedridden residents.
R3 had PRN (supplements) with a physician order without labels.
R2 last physician report was on 3/29/21 and R3's last physician report was on 9/14/21 per Title 22 Regulations residents with dementia must obtain a yearly assessment.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Cristina Chen - Assistant Administrator and a copy of this report, LIC 809D, and appeal rights.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
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 3


Document Has Been Signed on 10/24/2022 01:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: VISTA DEL MAR VILLAS
FACILITY NUMBER: 198602623

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2022
Section Cited

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87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the ... fire department, ...retaining any of the following types of persons, ... (2) Bedridden persons

This requirement is not met as evidence by:
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Based on document review licensee did not ensure R3's ambulatory status met the facility's license ambulatory status which poses an immediate health, safety, or personal rights risk to the persons in care.
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Type B
11/01/2022
Section Cited

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87465 Incidental Medical and Dental Care: (e) ... PRN medication for which the licensee provides assistance there shall ...label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidence by:
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Based on medication licensee did not ensure R3's PRN (supplements) are label which poses a potential health, safety, or personal rights risk to the persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/24/2022 01:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: VISTA DEL MAR VILLAS
FACILITY NUMBER: 198602623

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2022
Section Cited

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87705 Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458,...
This requirement is not met as evidence by:
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Based on document review licensee did not ensure R2 and R3 obtain a current physical assessment which poses a potential health, safety,and personal rights risk for persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3