198603458-8-14-2024-28-AS-CGUZ-D85KUZ-20240814081330

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603458
Report Date: 08/09/2024
Date Signed: 08/14/2024 08:13:37 AM

Document Has Been Signed on 08/14/2024 08:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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: 6	DATE:	08/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	Caregiver Melba Fojas		TIME COMPLETED:	03:55 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) Christian Gutierrez conducted an unannounced Annual Required Visit at 1:07 PM. LPA was met by Care giver Melba Fojas and explained the purpose of the visit. Administrator Apoloni Santos arrived shortly. Facility is licensed to serve residents over 60 years old six (6) can be non-ambulatory, of which two (2) may be bedridden in room #3. During today’s visit it was observed facility had bedridden resident in room one. Deficiency and civil penalty assessed. The facility is a single-story home, located in a residential area. The home consists of a living room, (4) residents’ bedrooms, (1) staff room, (2) resident bathrooms, a kitchen, dining room, attached garage, and shaded patio with seating in the backyard. LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. The facility has two (2) fully charged fire extinguishers which is kept in the kitchen and hallway. Cleaning supplies and toxic substances were observed to be inaccessible to clients and locked in kitchen cabinet. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Sharps are locked and placed in cabinet in kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The garage is clean and has extra supplies. SEE LIC 809C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian Gutierrez	TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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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Document Has Been Signed on 08/14/2024 08:13 AM - 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARS FOUNTAIN HOMES	FACILITY NUMBER: 198603458
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87204(a)

87204 Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one (1) out of six (6) residents R1 is bedridden and not in approved bedroom # 3 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2024
	Plan of Correction
1 2 3 4	Administartor agrees to move R1 to approved room shown on license and send proof to LPA via email

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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian Gutierrez	TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARS FOUNTAIN HOMES	FACILITY NUMBER: 198603458
	VISIT DATE: 08/09/2024

NARRATIVE

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Four (4) Staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Six (6) Client files were reviewed and included physicians report, TB clearance. Fire/earthquake was conducted on 06/02/2024. Infectious control plan was reviewed. The medications are centrally stored and locked in a closet at entryway of home. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all clients, and they are being administered as prescribed by the physician.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Apoloni Santos.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian Gutierrez	TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC809 (FAS) - (06/04)

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