198603116-8-5-2023-28-AS-THEA-CUEQUR-20230805122911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603116
Report Date: 08/05/2023
Date Signed: 08/05/2023 12:29:16 PM

Document Has Been Signed on 08/05/2023 12:29 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ROWLAND VISTA RESIDENTIAL CARE		FACILITY NUMBER:	198603116
ADMINISTRATOR:	PASCASIO, GLORIE		FACILITY TYPE:	735
ADDRESS:	1229 W ROWLAND AVE		TELEPHONE:	(626) 241-4891
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY: 4		CENSUS: 4	DATE:	08/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:22 AM
MET WITH:	Melissa Villanueva - House Manager		TIME COMPLETED:	12:30 PM

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Melissa Villanueva (House Manager) who assisted with the visit. The facility is licensed to serve 4 ambulatory clients ages 18 to 59 years old.

The facility is located in a residential area in West Covina, Ca. A tour of the single-story facility includes: living room, dining area, kitchen, 4 client bedrooms, 2 bathrooms, staff office, storage room, attached garage / laundry room, front yard, backyard and locked storage shed.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. There is sufficient PPE supplies and an Infection Control Plan.

Physical Plant & Environment Safety: There are 4 client bedrooms, 2 bathrooms, living room, kitchen, dining area, staff office, storage room, attached garage/laundry room, front yard and backyard. All bathrooms are clean and operational. Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility and are within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in a secured, locked area and inaccessible to clients. The last Fire/Emergency Drill was conducted on 07/19/23. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed and are fully charged.

(Continued on 809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2023

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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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: ROWLAND VISTA RESIDENTIAL CARE	FACILITY NUMBER: 198603116
	VISIT DATE: 08/05/2023

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Operational Requirements: There are currently 4 clients residing at the facility.
Staffing: There appears to be sufficient staffing at all times in the facility. There are 2 administrators at the facility who are in the pending stages of their renewal and were able to furnish proof of submitting renewal ahead of expiration. (Glorie Pascasio and Melissa Villanueva)
Personnel Records-Training: Staff has criminal record clearance and files are kept in a locked cabinet within the Staff Office. Staff have current CPR/first aid training and sufficient on-going training.
Client Rights-Information: Facility provides telephone and internet service for clients in care.
Client Records-Incident Reports: Client files are kept in a locked cabinet within the Staff Office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. During the visit today, LPA reviewed all 3 clients' medication no issues were observed. (one client currently at a skilled nursing facility)
Incidental Medical & Dental: All medications for clients are kept locked and inaccessible to other clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

During todays visit LPA interviewed 3 Staff and 2 Clients.

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 to House Manager Melissa Villanueva.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2023

LIC809 (FAS) - (06/04)

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