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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700853
Report Date: 08/15/2023
Date Signed: 08/15/2023 02:07:09 PM

Document Has Been Signed on 08/15/2023 02:07 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, 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: 6DATE:
08/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Monalisa Legaspi - AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Annual 1 Year Required Inspection visit. LPA met administrator and explained purpose of visit. Administrator certificate expires on June 15,2024.

LPA and administrator toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of seven bedrooms for residents of which six bedrooms are occupied by the residents and there is one break room. There are three and half bathrooms. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 72 degrees Fahrenheit. . The hot water temperature in the residents’ shared bathroom was measured at 111.7 degrees Fahrenheit which is in required range of 105 to 120 degrees. Night lights are maintained in hallways and passages to bathrooms. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of seven day supply of nonperishable and two day of perishable food. All Fire Exits are free of obstacles and last fire drill was completed on August 1, 2023.
Smoke and Carbon Monoxide alarms were tested. Fire Extinguisher was last inspected on January 24, 2023.

LPA reviewed two staff and two resident files. Resident emergency contact complete. LPA observed all staff and resident files complete. All staff have criminal record clearance and are associated to the facility.

LPA received the following updated documents for master file submitted on August 15, 2023: LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, Liability Insurance, Administrator Certificate, and Rental Agreement.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies are being cited today in violation of California Code of Regulations.

Exit interview held with administrator. A copy of report and LIC 811 - Confidential names was provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
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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