198603382-1-7-2021-28-AS-BTAO-BX32AG-20210107161331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603382
Report Date: 01/07/2021
Date Signed: 01/07/2021 04:14:21 PM

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:	ASPIRIA ADULT RESIDENCES		FACILITY NUMBER:	198603382
ADMINISTRATOR:	VILLA, MEYNARD		FACILITY TYPE:	740
ADDRESS:	342 W. PALM DRIVE		TELEPHONE:	(626) 672-8439
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91007
CAPACITY:	6	CENSUS: 0	DATE:	01/07/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Meynard Villa, applicant and Eliemar Villa, applicant		TIME COMPLETED:	04:00 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	Licensing Program Analyst (LPA), Tao conducted an announced pre-licensing inspection. This is an initial application applying for Residential Care for Elderly. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s pre-licensing inspection was conducted telephonically with Applicants. LPAs met Meynard Villa and Eliemar Villa, licensee applicants, at the virtual visit. The facility has a capacity of six (6). Its fire clearance is approved for five (5) non-ambulatory and one (1) bedridden. LPA observed zero resident at the time of the visit. The facility has a Dementia Care Program. The applicants are a Limited Liability Corporation, Aspiria Adult Residence LLC. The facility was a single-story home with five (5) client’s bedrooms, four (4) bathrooms, two (2) living rooms, a kitchen, a dining room, an activity area at the patio, a laundry room and a detached garage. The facility was located in a residential neighborhood. This facility was granted a fire clearance on September 1, 2020. LPA took a virtual tour for the physical plant including the inside and outside of the house including the garage. LPA observed the following: -Food storage and preparation areas were clean and in good repair. -Cooking / kitchen appliances were operational -Food utensils and dining wares were sufficient for its capacity. -Hot water was 120 degrees Fahrenheit which was within Title 22 Regulation guidelines. -Dishwashing soap/ detergents were stored in a locked cabinet and inaccessible to clients. ( - Continued in LIC 809-C )

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021

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: ASPIRIA ADULT RESIDENCES	FACILITY NUMBER: 198603382
	VISIT DATE: 01/07/2021

NARRATIVE

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-A refrigerator was maintained at 36 degrees Fahrenheit and the freezer was maintained at 0 degree Fahrenheit
-Two days of perishable food and seven days of non-perishable food were available.
-Sharp tools and knives were stored in a locked cabinet in the kitchen.
-Cleaning supplies and poisons solutions are stored in a locked cabinet.
-Medication was centrally stored in a medication cabinet and inaccessible to residents.
-Two fire extinguishers were fully charged which were located in the kitchen and hallway. The last service date was 09/01/20.
-Facility had central air and heating accommodations at 68 degrees Fahrenheit.
-Smoke and carbon monoxide detectors were operational. Hard wired to fire department.
-Linens supplies and personal hygiene supplies were adequate.
-Residents’ bedrooms were inspected for personal accommodations for safety, privacy, and comfort.
-Residents’ rooms were well furnished and in compliance.
-Grab bars are maintained for each toilet, bathtub and shower.
-Non- skid mats are installed in bathtubs and showers.
-Doors, stairways and passageway were unobstructed,
-Facility was in good repair with a TV in the living room.
-No pool or bodies of water in the facility
-No firearms in facility.
-A phone for residents was operational.
-First aid supplies and first aid manual were maintained
-Outdoor activity area, supplies, shaded area, chairs were furnished and in compliance.
-Detached garage as a storage. No bed setting is observed.
-Administrators had Criminal Background Clearance
-Personnel Report / LIC 500 were prepared. Licensee applicant stated that the staff records/ files would be updated when needed and more staff are hired.
-A current disaster plan maintained
( - Continued in LIC 809-C )

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021

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: ASPIRIA ADULT RESIDENCES	FACILITY NUMBER: 198603382
	VISIT DATE: 01/07/2021

NARRATIVE

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-The backyard was consisting of a shaded area with patio furniture.
-All emergency shut-offs are located outside of the house.
-Auditory device at the main entrance and exit doors are operable.

Dementia:
-Range is inaccessible to residents.
-Knives, tools, sharp items are inaccessible to residents.
-No swimming pool and other bodies of water at the facility.
-medication and toxic substances are inaccessible to residents.
-Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates.
-Auditory device to monitor exits were operable.
-Interior and exterior space available to permit residents to wander freely and safely.

Component III was conducted during this visit.

A virtual exit interview was conducted and a copy of this report was provided to Applicant, Meynard Villa and Eliemar Villa. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, s/he has been instructed to communicate with the CAB Analyst who assigned to his/her application.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021

LIC809 (FAS) - (06/04)

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