198603382-1-28-2022-28-AS-BTAO-CB4UFD-20220128143235

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603382
Report Date: 01/28/2022
Date Signed: 01/28/2022 02:32:46 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: 6	DATE:	01/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Meynard Villa, Licensee		TIME COMPLETED:	02:00 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 unannounced annual inspection visit. LPA met with Meynard Villa, Licensee, who assisted with today's visit. The facility has a capacity of six (6) residents. It is licensed to serve elderly residents age 60 and above, approved for six (6) non-ambulatory, of which one (1) may be bedridden. Facility approved for two (2) hospice waivers. Bedroom #5 is cleared for bedridden. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility is a single-story home consisted of five (5) resident’s bedrooms, four (4) bathrooms, living room, den, kitchen, dining room, activity area at the patio, laundry room and detached garage. The facility was located in a residential neighborhood. Administrator certificate is current and the expiration date is 10/31/2022. A physical tour was conducted. Residents’ rooms were well furnished and in compliance. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 119.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. No firearms on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely. (-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: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

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: 01/28/2022

NARRATIVE

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Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Dual detectors (Smoke detectors combined with carbon monoxide detectors) are operable. Fire extinguishers’ last service is 2/20/21 and are fully charged.

The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked cabinet in the kitchen and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates.

Deficiency was observed and cited per California Code of Regulations, Title 22 in LIC 809 D.

An exit interview was conducted. This report is discussed and provided to facility Licensee /Administrator, whose signature on this form confirm receipt of these documents. A copy of appeal rights was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the cover of the dishwasher is missing. This poses a potential health and safety risk to residents.
	POC Due Date: 02/11/2022
	Plan of Correction
1 2 3 4	Licensee agreed to fix/replace the dishwasher cover by the due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

LIC809 (FAS) - (06/04)

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