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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603556
Report Date: 06/01/2023
Date Signed: 06/01/2023 01:15:48 PM

Document Has Been Signed on 06/01/2023 01:15 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:NAVILLA VISTA RESIDENTIAL CAREFACILITY NUMBER:
198603556
ADMINISTRATOR:PASCASIO, GLORIEFACILITY TYPE:
735
ADDRESS:672 E. NAVILLA PLTELEPHONE:
(626) 241-4891
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY: 4CENSUS: 4DATE:
06/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Glorie PascasioTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with the DSP Danielle Tena who allowed the entry of the facility and later on, the administrator Glorie Pascasio arrived and assisted with the visit. The purpose for the visit was explained. The facility is licensed for age range 18 through 59 for non-ambulatory.

LPA Wong utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and here are the domains that LPA inspected:

1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting at least once a day and more often for high touched surfaces area. Facility has sufficient PPE supplies and has an Infection Control Plan.
2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, kitchen, dining area, staff office, activity/family room, four clients bedrooms, two clients bathrooms, medication closet and attached garage. All clients bedrooms have one bed, night stand, chair, table, drawer, closet, required bedding and sufficient closet space and lighting. All two clients bathrooms are clean, sanitize and in a operable condition. The hot water temperature tested in two bathrooms were between 119.6 and 120 degrees F which is within the Title 22 regulation. LPA inspected the smoke detectors and carbon monoxide detectors and they are interconnected and located in each clients bedrooms and common area and they are working probably. The facility room temperature is within the required limit. LPA also observed the facility has ample supply of personal hygiene products and they are stored in the medication closet. The facility also has a telephone service on the premises.
3. Operational Requirements: The facility maintained a fire clearance approved by the fire department which they currently have all four non ambulatory clients only. The facility also has shaded area with table and chair for client to utilize for outdoor activity. The last fire and disaster drill was conducted on 3/3/23
(See LIC 809C for continuation)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NAVILLA VISTA RESIDENTIAL CARE
FACILITY NUMBER: 198603556
VISIT DATE: 06/01/2023
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4. Staffing: The facility has sufficient staffing in the facility. The night staff has an updated facility planned emergency procedure training on file.
5. Personnel Records-Training: All staff files are available for LPA to be reviewed in the facility and stored at the staff office. The facility administrator Glorie Pascasio and her administrator certificate expired on 1/4/23 but CCL received her application on 1/31/23 and currently the application is pending. Administrator does have an updated HIV and TB training in file. All staff are over 18 years old and they are all fingerprinted and associated with the facility and they all have the required documents in their personnel files. All staff also have an updated training including medication management and first aid.
6. Clients Right-Information: The facility does not have any client required postural support. The facility does serve adults has internet service shall provide at least one access device.
7. Clients Records-Incident Reports: All clients' files are available to be reviewed in the facility and stored in the staff office. All client files have the required documents which included admission agreement, face sheet, Individual Personal Plan (IPP), updated physician report and functional capability assessment,
8. Food Services: The facility has the minimum of two days perishable and seven days non-perishable food supply in the facility. The refrigerator is maintained in the required temperature. All the food are stored probably.
9. Health Related Services: All client medication are centrally stored and locked in the medication closet. LPA inspected all four (4) clients medication and they are all seemed accurate and have an updated MARS. The first aid kit has all the required items and updated First Aid Manual and stored and locked in the medication closet. Staff also have required medication training in their personnel file.
10. Incidental Medical Services: The facility has no clients with prohibited health condition but the facility currently has one client with restricted health condition. The client has the required restricted health condition plan in file and signed by the client's primary physician. All staff received the in service training from the licensed nurse regarding about the restricted health condition plan.
11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan and the staff received the training annually. The facility also has at least two available and alternative sites for relocation during emergency.
12. Emergency Intervention: Its not applied to the facility but all staff received Pro-Act training and its updated.

No deficiencies were observed during the visit.

Exit Interview conducted and the copy of the report was provided to the Administrator Glorie Pascasio.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC809 (FAS) - (06/04)
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