198603556-6-8-2022-28-AS-CWOG-CF7TNL-20220608145256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603556
Report Date: 06/08/2022
Date Signed: 06/08/2022 02:53:13 PM

Document Has Been Signed on 06/08/2022 02:53 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:	NAVILLA VISTA RESIDENTIAL CARE		FACILITY NUMBER:	198603556
ADMINISTRATOR:	PASCASIO, GLORIE		FACILITY TYPE:	735
ADDRESS:	672 E. NAVILLA PL		TELEPHONE:	(626) 241-4891
CITY:	COVINA	STATE: CA	ZIP CODE:	91723
CAPACITY: 4		CENSUS: 0	DATE:	06/08/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Gloria Pascasio-Licensee		TIME COMPLETED:	02:45 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 (LPAs),Christine Wong and Bennette Pena , conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPAs met withe licensee Gloria Pascasio. An application was submitted to CCLD on 2/1/22, for Initial License for a Adult Residential Facility to serve Developmentally Disabled Adults ages 18 to 59 years. The requested capacity is for 4 non-ambulatory only. Structure: Facility is a 4 bedroom, 2 bathroom, single story house with a two cars attached garage. The facility also includes kitchen, living room, dining area, staff office, medication closet, linen closet and a den/activity room. The client bedrooms are spacious and will easily accommodate the client's furnishings. The front and back yard are maintained well and the back yard has a shared area with table and chairs. The passageways and drive way are free from obstructions. The front, back and side areas of free of hazard. Bedrooms Residents: Each bedroom has one bed, one chair, one night stand, one drawer, required furniture and sufficient lighting and closet space. Bedroom Staff No bedroom designated for awake-staff. Bathrooms: All bathrooms have a working toilet and shower. There are two bathrooms in the facility and all will accommodate non-ambulatory clients in a wheel chair.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

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: NAVILLA VISTA RESIDENTIAL CARE	FACILITY NUMBER: 198603556
	VISIT DATE: 06/08/2022

NARRATIVE

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Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in linen closet next to the bathroom#1.

Emergency Phone Numbers, Exit Plan & Menu:
The facility telephone system is landline system and the phone number is 626-598-4164.
Posted & readily available for review next to the dining area. Fire Extinguisher located near the kitchen and the exit door next to the bedroom#3

Food Service:
Dishes, cups and flat ware are stored in the kitchen cabinets, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored and locked in the kitchen cabinet . Food supply adequate stored in the refrigerator and kitchen cabinet and consists of the following: 2 days perishable and 7 days non-perishable. Dishwasher in kitchen properly installed and functioning well.

Smoke Detectors:
The smoke detectors and carbon monoxide detectors are located in each bedroom and common area and they are all interconnected and working properly.

Appliances:
Stove, oven, microwave, washer, and dryer are working well. There are two refrigerators in the home, one in the kitchen and one in the garage for additional food storage. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat.

Toxins:
All toxins and cleaning supplies are locked and stored in the garage cabinet which is inaccessible to clients.

Water Temperature:
The two bathrooms was tested at 116.2 degrees F. which is within the Title 22 regulation.
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SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

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: NAVILLA VISTA RESIDENTIAL CARE	FACILITY NUMBER: 198603556
	VISIT DATE: 06/08/2022

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Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in the medication closet, available for staff use but inaccessible to clients.

Clients & Staff Files:
Applicant will be handling cash resources of clients and has a surety bond for $3000, cash resources will be locked and stored in lock box in the staff office with P & I Ledger, accessible to designated staff. Records of staff and clients shall be stored in a locked cabinet in staff office.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation and its located in the den area/activity room.

Pool/Jacuzzi & Pets:
None

Fire clearance:
Fire Clearance with four non-ambulatory was approved on 5/3/22

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

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

LIC809 (FAS) - (06/04)

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