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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881223
Report Date: 10/12/2023
Date Signed: 10/12/2023 07:38:58 PM


Document Has Been Signed on 10/12/2023 07:38 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ARYA SENIOR CARE HOMEFACILITY NUMBER:
361881223
ADMINISTRATOR:IMTIAZ, KANWALFACILITY TYPE:
740
ADDRESS:18554 OLALEE WAYTELEPHONE:
(626) 241-4585
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:6CENSUS: 6DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
06:18 PM
MET WITH:Kanwal ImtiazTIME COMPLETED:
07:45 PM
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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Kanwal Imtiaz and was granted entry to the facility. Licensed capacity is (6) current census (6). LPA was accompanied by Facility Administrator Kanwal Imtiaz to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. All sharps are locked. There was a designated office for client/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed (3) client files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (3) client medications. LPA also reviewed (3) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ARYA SENIOR CARE HOME
FACILITY NUMBER: 361881223
VISIT DATE: 10/12/2023
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Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Kanwal Imtiaz.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC809 (FAS) - (06/04)
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