198603458-8-25-2021-28-AS-LMAZ-C692DR-20210825171846

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603458
Report Date: 08/25/2021
Date Signed: 08/25/2021 05:18:58 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:	ARS FOUNTAIN HOMES		FACILITY NUMBER:	198603458
ADMINISTRATOR:	SANTOS JR., APOLONIO C.		FACILITY TYPE:	740
ADDRESS:	2668 FAWN CIRCLE		TELEPHONE:	(909) 575-7612
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	6	CENSUS: 0	DATE:	08/25/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Licensee, Apolonio Santos Jr.		TIME COMPLETED:	05:20 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 Analysts (LPA), Linda Almaraz conducted a visit to the above facility for a PRE-LICENSING evaluation. LPA met with Licensee's, Apolonio Santos Jr. and Rowena Santos. LPA did a walk through of the facility with the assistance of both Mr and Mrs. Santos. Structure: Facility is a (4) bedroom, (1) staff bedroom, (2) bathroom, single-story house. The home has a living room, dining room, large kitchen, and laundry room. There is a medium size back yard with shade. The residents bedrooms are spacious and will easily accommodate the resident's furnishings. The facility also has a garage that will not be accessible to residents. Signal system: All exits doors are equipped with a sensor type alarm systems which alerts staff. Bedrooms Residents: Bedrooms are approved for (4) non-ambulatory residents and (2) bedridden residents in Room #3. All bedrooms have the required bed(s), chair(s), night stand(s), and lamp(s). Laundry Room: Laundry room has a washer and dryer. Laundry supply is secured and locked separately. Bathrooms: All bathrooms have a working toilet, wash basin, and shower. There is two (2) bathrooms in the facility. Water temperature was within required range of 105-120 degrees F. (Continued on an LIC-809-C)

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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: ARS FOUNTAIN HOMES	FACILITY NUMBER: 198603458
	VISIT DATE: 08/25/2021

NARRATIVE

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Linens & Hygiene Supplies:
Beds have linen/supplies which include, pillowcase, fitted sheet, blankets and bedspreads. Adequate supply of linen stored in the linen hallway closet.

Emergency Phone Numbers, Exit Plan & Menu:
Facility’s telephone system is landline. Numbers posted & readily available for review. Fire Extinguishers are located in the dining room and hallway.

Food Service:
Dishes, cups and utensils are stored in the kitchen inspected and in good repair. Food supply adequate for seven (7) days of non-perishables.

Smoke Detectors:
Electrical & connected and appear to be operational. Carbon monoxide detector is located in the hallway and near the rooms and are operational.

Appliances:
Stove burners, oven, microwave, washer, and dryer are working. There is (2) large refrigerators in the home, a third small one is located in the medication closet room which will be utilized for refrigerated medication, one of the large refrigerators is located in the kitchen for food, an extra one in the garage. Dishwasher in kitchen is properly installed and appears to be functioning. The facility is equipped with central air and heating and each residents bedrooms are comfortable in temperature.

Medications, First-Aid Kit & Book:
A first-aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, which are stored in the medication closet room, available for staff use but inaccessible to residents. (Continued on LIC 809-C)

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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: ARS FOUNTAIN HOMES	FACILITY NUMBER: 198603458
	VISIT DATE: 08/25/2021

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Residents Records & Staff Files:
Applicant will not be handling cash resources of residents, therefore no Surety Bond will be required. Records of staff and residents will be stored in the medication closet room.

Reading Material, Games, Equipment & Materials:
The facility has board games, crossword puzzle game and game cards for the resident's to use.

Fire clearance:
Fire Clearance was approved on 5/25/21.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance was discussed.

Facility has not met the physical plant requirement per California Code of Regulations Title 22 Division 6 Chapter 8 and has to complete the following within 7 days:

Patio Furniture
Mattress Pads
COVID-19 screening visitor log
Hygiene supply
N95's and Face shields/goggles for at least 30 days
Lock/secure shed outside
Remove all debris/old furniture from the backyard
Closet space for all rooms
Post Theft and loss policy, and Labor laws for employees
First Aid Manual

Applicant shall submit pictures/video to LPA as proof of correction via email/fax by 9/1/2021.

An exit interview was conducted with Applicant and copy was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC809 (FAS) - (06/04)

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