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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700853
Report Date: 08/02/2022
Date Signed: 08/03/2022 07:55:40 AM

Document Has Been Signed on 08/03/2022 07:55 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ASTORIA VISTAFACILITY NUMBER:
342700853
ADMINISTRATOR:QUIDILIG, KARENFACILITY TYPE:
740
ADDRESS:8616 BANFF VISTA DRIVETELEPHONE:
(916) 714-4897
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Mona Lisa SilapanTIME COMPLETED:
03:45 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) R. Campbell conducted an unannounced Annual 1-Year Required visit on this date. LPA met and toured with Administrator, Mona Silapan. The administrator currently holds a certificate (#6025978740) that expires on 03/23/23.. Upon entry LPA was screened for COVID symptoms, a sign in/sign out procedure was observed as well as facility staff wearing masks.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms of which 5 bedrooms are occupied (1 resident bedroom is unoccupied) by the residents and 1 bedroom is occupied by staff. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 02/03/23. First aid kit was observed to be complete. Fire drill was last conducted on 06/03/2022 quarterly.

LPA reviewed 3 out of 5 staff record files and the facility has sufficient staffing to provide the services needed to meet the residents’ needs. All staff have criminal record clearance and are associated to the facility. All staff have current first aid training. The facility serves residents with dementia and staff have received the necessary training hours specific to dementia. A mattress and bed frame were found in the backyard.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 ,and California Health and Safety Code. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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 2
Document Has Been Signed on 08/03/2022 07:55 AM - It Cannot Be Edited


Created By: Renee Campbell On 08/02/2022 at 02:35 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ASTORIA VISTA
FACILITY NUMBER: 342700853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2022
Section Cited

1
2
3
4
5
6
7
(a) The facility shall be clean, safe, sanitary and in good repair at all times. for the safety and well-being of residents, employees and visitors.... This regulation was not met as observed by a mattresses and bedframe near the fire clearance.

1
2
3
4
5
6
7

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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:Liza King
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2