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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004247
Report Date: 09/11/2023
Date Signed: 09/11/2023 12:18:51 PM

Document Has Been Signed on 09/11/2023 12:18 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:
09/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mamie Palmon, Hector ObarTIME COMPLETED:
12:30 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Mamie Palmon and discussed the purpose of the inspection. Administrator (AD) Hector Obar arrived during the inspection.

LPA reviewed Infection Control requirements. At about 9:45AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 7-bedroom, 3-bathroom, two-story house with an attached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPA observed 2 staff and 2 clients present at the facility. Client Bedrooms: the 4 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: LPA inspected the 3 staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 109 degrees F in the first floor common bathroom, 118 in the first floor bedroom bathroom, and 119 degrees F in the second floor bathroom after corrections. LPA inspected all rooms in the facility. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility representative stated the facility licensing fees are paid. At about 10:15AM, LPA reviewed 2 client files and 6 staff files, interviewed 2 clients and 2 staff, inspected medications for 2 clients, and inspected client money and ledgers for 2 clients.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
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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Document Has Been Signed on 09/11/2023 12:18 PM - It Cannot Be Edited


Created By: Sean Haddad On 09/11/2023 at 12:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: VENTANA ARF - LA SIERRA
FACILITY NUMBER: 306004247

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not secure laundry detergent and flu medication in an upstairs room accessible to clients and which could not be locked, which poses a potential health and safety risk to persons in care.
POC Due Date: 09/25/2023
Plan of Correction
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During the inspection, the licensee secured these items and LPA confirmed. POC CLEARED.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the 1st floor bedroom bathroom tested at 125.4 degrees F and the 2nd floor common bathroom tested at 126.5 degrees F, which poses a potential health and safety risk to persons in care.
POC Due Date: 09/25/2023
Plan of Correction
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During the inspection, the licensee corrected the water temperature and LPA confirmed. POC CLEARED.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/11/2023 12:18 PM - It Cannot Be Edited


Created By: Sean Haddad On 09/11/2023 at 12:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: VENTANA ARF - LA SIERRA
FACILITY NUMBER: 306004247

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility has a second floor which clients can access but does not have an evacuation chair, which poses a potential safety risk to persons in care.
POC Due Date: 09/25/2023
Plan of Correction
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During the inspection, the licensee purchased an evacuation chair for delivery and LPA confirmed. POC CLEARED.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023


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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VENTANA ARF - LA SIERRA
FACILITY NUMBER: 306004247
VISIT DATE: 09/11/2023
NARRATIVE
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During the inspection, LPA and AD observed the following: the licensee did not secure laundry detergent and flu medication in an upstairs room accessible to clients and which could not be locked; the 1st floor bedroom bathroom tested at 125.4 degrees F and the 2nd floor common bathroom tested at 126.5 degrees F; and the facility has a second floor which clients can access but does not have an evacuation chair. AD stated that the clients are always supervised, generally 1 on 1. All of these issues were corrected during the inspection.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC809 (FAS) - (06/04)
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