198603556-5-30-2024-28-AS-CWOG-D5RTTQ-20240530150108

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603556
Report Date: 05/30/2024
Date Signed: 05/30/2024 03:02:32 PM

Document Has Been Signed on 05/30/2024 03:02 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 CARE		FACILITY NUMBER:	198603556
ADMINISTRATOR/ DIRECTOR:	PASCASIO, GLORIE		FACILITY TYPE:	735
ADDRESS:	672 E. NAVILLA PL		TELEPHONE:	(626) 241-4891
CITY:	COVINA	STATE: CA	ZIP CODE:	91723
CAPACITY: 4		CENSUS: 4	DATE:	05/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:25 AM
MET WITH:	Glorie Pascasio		TIME VISIT/ INSPECTION COMPLETED:	03:30 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) Wong conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Mayra Rufino , House Manager at the facility and was granted access into the home. Administrator Glorie Pascasio arrived shortly to assist the annual inspection. The facility is vendored as Level 4I (Code 113) through the San Gabriel/Pomona Regional Center

1. Infection Control: Facility has an updated infection control plan in place. Facility staff continue to practice hand washing with clients and disinfect the high touch service area several times a day. Facility has sufficient PPE supplies.

2. Physical plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: kitchen, living room, dining area, staff office, activity room, medication closet, linen closet, four client's bedrooms and two client's bathrooms and an attached garage. All four client's bedrooms have one bed, one chair, one drawer, one night stand, required beddings and furniture and sufficient lighting and closet space. The two client's bathrooms are clean, sanitary and in a good working condition. The two client's bathrooms hot water temperature were tested between 116.7 and 116.9 degrees F which is within Title 22 regulation. All the sharp knives and utensils are stored and locked in the kitchen drawer. All the kitchen appliances are working properly. The chemicals and cleaning supplies are stored and locked in the cabinet in the garage. The carbon monoxide detectors and smoke detectors are interconnected and they are working well. The extra personal hygiene products are stored and locked in the medication closet. The hallway light is always on during night time for client to access the non-private bathrooms. The hallway also has a sensor light. The facility has a telephone service on the premises.

3. Operational Requirement: Facility is licensed for four non-ambulatory and currently three clients is non-ambulatory and one is ambulatory which is within the fire clearance requirement. The last fire drill was conducted on 12/7/23 and the last earthquake drill was conducted on 12/12/23. The client would be able to participate community events or activities if there's an opportunity. The facility has a shaded area with table and chairs in the backyard for client to utilize the outdoor activity.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

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 5

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: 05/30/2024

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

4. Staffing: Facility has sufficient staffing to provide care and supervision to clients. The NOC shift staff has the required facility planned emergency procedure training.

5. Personal Records-Training: All staff files are stored in the staff office. All the staff are over 18 years old, fingerprint cleared and associated with the facility. All the staff files have the required documents included: employment application, health screening and TB test result, required training hours and required license and updated First Aid Certificate. The administrator is Glorie Pascasio and her administrator certificate is effective through 1/4/25 and she has the required HIV and TB training.

6. Client's Right: No clients required any postural support in the facility. The facility has internet service and provide at least one internet access device which is equipped with video conferencing with their family, day program or primary physician if needed.

7. Food Service: The facility has sufficient two days perishable and seven days non-perishable food supply. All the food are stored properly in the facility. No client is on any modified diet that's prescribed by the doctor.
8. Client's Record-Incident Reports: All the client's files are stored in the staff office. All the client's files have the required documents which included: face sheet, functional capacity assessment, admission agreement, Individual Program Plan (IPP), updated physician and dental report and TB test result, ambulatory status and medication list.

9. Health Related Services: All clients' medication are stored and locked in the medication closet. LPA inspected all four clients' medication and they all seemed accurate. All clients have the 30 days supply of medication. The facility would assist and arrange client's medical and dental appointment. LPA also inspected the facility first aid kit and they have all the required supplies.

10. Incidental Medical Services: Currently there's one client has required restricted health condition care plan in the facility and has the required documents in client's file which is included the updated restricted health condition care plan signed by client's primary physician and service coordinator and the staff have the required training for client's restricted health condition.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: 05/30/2024

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

11. Disaster Preparedness: The facility has an updated Emergency and Disaster Plan (LIC610D) . The facility has two alternative shelter location available.

12. Emergency Intervention: The facility does not use any restraint on clients but all staff have the updated Pro-Act Training Certificate.

No deficiencies were observed during the annual inspection.

Exit Interview, a copy of the report was provided to the administrator Glorie Pascasio.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5