<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004247
Report Date: 08/01/2022
Date Signed: 08/01/2022 12:51:14 PM

Document Has Been Signed on 08/01/2022 12:51 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VENTANA ARF - LA SIERRAFACILITY NUMBER:
306004247
ADMINISTRATOR:HECTOR OBARFACILITY TYPE:
735
ADDRESS:26911 LA SIERRA DRTELEPHONE:
(949) 916-0084
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 2DATE:
08/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Bryan PelayoTIME COMPLETED:
01:05 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
On 08/01/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Ventana ARF- La Sierra. The purpose of today's visit was to conduct a Required 1 Year inspection focusing on the Infection Control. At 10:13am, LPA Cho was allowed entry into the facility and met with House Manager (HM) Bryan Pelayo after completing the Coronavirus 2019 (COVID-19) screening procedure. Caregivers Richard Nessia, Lee Palmon, and Mamie Palmon were present at the facility. The Administrator's Certificate for Hector Obar expired on 05/14/2022. Administrator (Admin) Hector Obar stated all required course work have been completed and Admin has agreed to submit the completed course work via email to LPA by today's date.

The facility is a two-story structure and licensed for six clients of which two are non-ambulatory. This facility offers a Level 4I service. As of today, there are two clients living in the facility of which two are ambulatory. LPA observed two clients present watching television in the living room.

At 10:30am, LPA Cho conducted a tour of the physical plant along with HM Pelayo. The facility consists of four client bedrooms and two client bathrooms. There are four private staff bedrooms and 1 private staff bathroom on the second floor. The facility also has a living room, family room, dining room, kitchen, and an attached two car garage/laundry area. The clients' bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each client comfortably. All client bedrooms were free of clutter and debris. No clients were occupying Bedrooms #1 and #4 at this time. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and showers were free of mold/mildew. At 10:51am, LPA Cho entered Client Bathroom #1 which smelled strongly of urine. HM Pelayo stated that Client #1 has difficulty urinating and at times would miss the toilet. Bathroom #1 was cleaned and sanitized during the visit. Urine odor is no longer present. Client bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA Cho tested the hot water temperatures in two client bathrooms which measured at 117.3 degrees Fahrenheit in Bathroom #1 and 117.8 degrees Fahrenheit in Bathroom #2.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2022
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VENTANA ARF - LA SIERRA
FACILITY NUMBER: 306004247
VISIT DATE: 08/01/2022
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
LPA Cho inspected the kitchen along with HM Pelayo. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was serviced and fully charged. The smoke, carbon monoxide detectors, and auditory alarms were tested and operational. Medications and sharps were locked and inaccessible to clients.

LPA Cho toured the outside grounds with HM Pelayo. The pool was gated and locked. There was ample shading and sufficient seating for clients. Walkways around the facility were clear of hazards and the side gate was self-closing and self-latching. There were no security bars or weapons on the premises.

Client and staff files were not reviewed at the time of the visit. Facility records were reviewed at the time of the visit which includes the following: Personnel Report (LIC500), Emergency and Disaster Plan for Adult Residential Facilities (LIC610D), and the Mitigation Plan. The facility does not have an updated LIC610D form and does not have the Infection Control Plan. To ensure compliance, LPA Cho emailed the PINs during the visit. Facility to submit the updated LIC610D and Infection Control Plan to LPA Cho. Facility has back-up emergency food and water supply including PPEs stored in the garage. The First Aid Kit met all the required components except a First Aid Manual.

LPA Cho reviewed Assembly Bill 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. Clients have access to a smart phone upon request.

LPA Cho reviewed the COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102) were issued during the visit. An exit interview was conducted with House Manager Bryan Pelayo, and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7