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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603116
Report Date: 07/16/2024
Date Signed: 07/16/2024 12:40:31 PM

Document Has Been Signed on 07/16/2024 12:40 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:ROWLAND VISTA RESIDENTIAL CAREFACILITY NUMBER:
198603116
ADMINISTRATOR/
DIRECTOR:		PASCASIO, GLORIEFACILITY TYPE:
735
ADDRESS:1229 W ROWLAND AVETELEPHONE:
(626) 241-4891
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 4CENSUS: 4DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:House Manager Melissa VillanuevaTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with House Manager Melissa Villanueva and explained the reason for the visit. The physical plant was inspected along with medications, food supply, and resident and staff records. The facility is licensed to serve developmentally disable clients between the ages 18 to 59. Approved for four (4) non-ambulatory client. There are currently 4 clients residing at the home and receive services from San Gabriel / Pomona regional Center.
LPA and House Manager toured the home and inspected (4) client bedrooms, (2) bathrooms, kitchen, dining room, living room, exercise room, office room, and attached garage. Laundry area was observed in the 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 clients located in the backyard. Passageways and exits are free of obstruction.
LPA observed laundry detergent, cleaning solutions/disinfectants are stored and locked in the garage. Client bedrooms were checked. Each bedroom is equipped with the proper furnishings. Bedrooms also have sufficient closet space. The bathrooms were toured. Bathrooms are clean and have the required hygiene items. The water temperature was tested in both bathrooms and measured at 107.8F in bathroom #1 and 114.2F in bathroom #2 which is within the required 105 - 120 degrees. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked in a kitchen drawer and are inaccessible to clients. The fire extinguishers observed to be fully charged. Smoke/carbon monoxide detectors were observed to be fully operational. All clients medications were reviewed.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ROWLAND VISTA RESIDENTIAL CARE
FACILITY NUMBER: 198603116
VISIT DATE: 07/16/2024
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Medications are centrally stored in cabinets located in the kitchen. Medications are documented properly and given as prescribed. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed client files to confirm emergency contacts have been updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed. Last emergency/ fire drill was conducted on 04/08/24.


No deficiency was observed during today's visit. Exit interview was conducted with the House Manager and a copy of report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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