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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603382
Report Date: 03/10/2023
Date Signed: 03/10/2023 05:56:07 PM


Document Has Been Signed on 03/10/2023 05:56 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:ASPIRIA ADULT RESIDENCESFACILITY NUMBER:
198603382
ADMINISTRATOR:VILLA, MEYNARDFACILITY TYPE:
740
ADDRESS:342 W. PALM DRIVETELEPHONE:
(626) 672-8439
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:6CENSUS: 6DATE:
03/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Staff, Lamasha Anderson and
Administrator, Meynard B Villa		TIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Lamosha Anderson, staff, who assisted with today's visit until 2pm and Administrator, Meynard B Villa assisted with the visit after 2pm. 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. Annual fees are current.

During the visit, the inspection tool was used, staff and residents were interviewed, a facility tour 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.

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 above 120 degrees Fahrenheit which was NOT 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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023
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 5


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: 03/10/2023
NARRATIVE
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Sufficient supply of perishable and nonperishable food is observed. Knives, tools, sharp items are inaccessible to residents. Dual detectors (smoke detectors combined with carbon monoxide detectors) are operable, monitored by fire prevention company ADT and wired to fire department. Fire extinguishers’ last service is 3/10/23 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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/10/2023 05:56 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: ASPIRIA ADULT RESIDENCES
FACILITY NUMBER: 198603382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Water temperature was checked at the kitchen sink (measured at 128 degree F) and resident bathroom (measured at 126 degree F).
Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2023
Plan of Correction
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Licensee agreed to adjust the water broiler of the tap water and keep the range from 105 degree F to 120 degree F. A water temperature log will be sent to Licensing by 3/11/23. A week log of daily water temperature (from 3/11/23- 3/17/23) will be sent to Licensing to ensure the water temperature is consistant and within the range of 105-120 degree F.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 03/10/2023 05:56 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: ASPIRIA ADULT RESIDENCES
FACILITY NUMBER: 198603382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Personnel records of staff#1 to staff #5 were incompleted which were either missing copies of LIC 501(personal records), LIC503 (Health screening), LIC508, LIC 9052 (employee right), TB records, or in-service training.
Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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Licensee agreed to print out and compile the staff files Send photo of the files to Licensing to show proof the files were complete by the POC due date.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Resident files of resident#1, #3 and #6 were missing pre-admission appraisal, and Appraisal/ needs and service plan. Resident#3 and #6's file were missing admission agreement.
Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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Licensee agreed to complete resident#1, #3 and #6 's pre-admission appraisal, and Appraisal/ needs and service plan. Send photo of the files to Licensing to show proof the files were complete by the POC due date.
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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 03/10/2023 05:56 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: ASPIRIA ADULT RESIDENCES
FACILITY NUMBER: 198603382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Resident files of resident#2, and #4 's Appraisal/ needs and service plan were out-dated.
Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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Licensee agreed to complete resident#2, and #4's updated Appraisal/ needs and service plan. Send photo of the files to Licensing to show proof the files were complete by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5