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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603556
Report Date: 07/08/2025
Date Signed: 07/09/2025 09:51:35 AM

Document Has Been Signed on 07/09/2025 09:51 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:NAVILLA VISTA RESIDENTIAL CAREFACILITY NUMBER:
198603556
ADMINISTRATOR/
DIRECTOR:		PASCASIO, GLORIEFACILITY TYPE:
735
ADDRESS:672 E. NAVILLA PLTELEPHONE:
(626) 241-4891
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY: 4CENSUS: 4DATE:
07/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:18 PM
MET WITH:House Manager- Mayra RufinoTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) S Vaid conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement 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 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.

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 the required beddings and furniture and sufficient lighting and closet space. The four client's bathrooms are clean, sanitary and in a good working condition. The two client's bathrooms hot water temperature were tested between 106.7 and 108.2 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 nighttime. The hallway also has a sensor light. The facility has a telephone service on the premises.
CONTINUED 809C.............
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: NAVILLA VISTA RESIDENTIAL CARE
FACILITY NUMBER: 198603556
VISIT DATE: 07/08/2025
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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 5/22/25 and the last earthquake drill was conducted on 5/19/25. 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.

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 1/4/27 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.

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 is stored and locked in the medication closet. LPA inspected all four clients' medication, and they all were observed 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.
CONTINUED ON 809C..................
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
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: NAVILLA VISTA RESIDENTIAL CARE
FACILITY NUMBER: 198603556
VISIT DATE: 07/08/2025
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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 has 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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
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