198603458-9-26-2022-28-AS-BTAO-CJMRZX-20220926132839

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603458
Report Date: 09/26/2022
Date Signed: 09/26/2022 01:28:46 PM

Document Has Been Signed on 09/26/2022 01:28 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:	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: 5	DATE:	09/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Luis Santos, administrator		TIME COMPLETED:	12:15 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 Luis Santos, administrator, who assisted with visit. Facility is licensed to serve six (6) non-ambulatory residents, of which two (2) bedridden, ages 60 and over. Six (6) hospice waivers on file. Annual licensing fees are current. Room#3 is approved for bedridden. Administrator certificate is current. 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 single-story house located in a residential neighborhood in the city of La Verne. LPA toured the facilities physical plant, indoor and outdoor. The facility has four (4) bedrooms, one (1) staff bedroom, and two (2) bathroom. The home has a living room, dining room, large kitchen, and laundry room. There is a medium size back yard with shade. All the rooms were furnished with appropriate furniture for residents’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water 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. Sufficient supply of perishable and nonperishable foods was observed. Knives, tools, sharp items were inaccessible to residents. Smoke detectors and carbon monoxide detectors were operable. Fire extinguishers are fully charged. Fire drill was conducted on 8/24/22. (-continued in LIC 809C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

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 2

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: 09/26/2022

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
26
27
28
29
30
31
32

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 Med storage room next to the exit and inaccessible to residents. Resident records are stored, locked 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.

No deficiencies was observed and cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report was discussed with Administrator. Staff’s signature on this form confirmed receipt of these documents. A copy of LIC 809s report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2