365530197-3-5-2024-56-AS-MECA-D33NX2-20240305095027

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530197
Report Date: 03/05/2024
Date Signed: 03/05/2024 09:50:35 AM

Document Has Been Signed on 03/05/2024 09:50 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ARYA GARDEN ASSISTED LIVING		FACILITY NUMBER:	365530197
ADMINISTRATOR:	IMTIAZ, KANWAL		FACILITY TYPE:	740
ADDRESS:	11143 LANCER LANE		TELEPHONE:	(626) 241-4585
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY:	6	CENSUS: 0	DATE:	03/05/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Kanwal Imtiaz-Administrator		TIME COMPLETED:	09:55 AM

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) Michelle Echeverria , arrived at Arya Garden Assisted Living , to conduct an announced Pre-Licensing visit for licensure. LPA was greeted by Administrator, Kanwal Imtiaz. LPA introduced self and stated purpose of the visit. LIC200 application was submitted on 11/10/23 for (5) non-ambulatory residents and (1) bedridden resident. Fire Safety Inspection clearance was granted for (5) non-ambulatory residents and (1) bedridden resident on 01/19/24. LPA toured the facility inside and outside and observed the following: Structure: Facility is a one story house with (5) resident bedrooms, (3) resident bathrooms, living room, dining area, kitchen, pantry, laundry room, backyard, and attached garage. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: Each resident bedroom accommodates one non-ambulatory resident except for bedroom #1 which accommodates one bedridden and one non-ambulatory residents. Bathrooms: The resident bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives, sharps, detergent and chemicals are stored in locked cabinets/closet. There was a pantry stocked with non-perishable food and perishable food found in the refrigerator. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. Water tested in the bathroom faucet measured at 118 degrees fahrenheit. Laundry room has a functional washer and dryer.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

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 GARDEN ASSISTED LIVING	FACILITY NUMBER: 365530197
	VISIT DATE: 03/05/2024

NARRATIVE

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Living/Family room: There was a furnished living room with one enclosed fireplace, board games and tv observed.

Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies stored in a closet.

Yards/Outside: A self-latching handle gate on the left side of the house that leads into the backyard. There are no firearms, ammunition, swimming pool or bodies of water observed. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan: Facility sketch, CCL complaint poster, house rules, personal rights, Emergency and Disaster Plan and ombudsman were observed posted in the hallway.

General items: The smoke and carbon monoxide detectors were tested and are operable. There was fully charged fire extinguishers observed. Resident/Staff records stored in a locked filing cabinet inside the garage. First Aid kit with required components, and a locked area for medication storage was observed. LPA observed a facility phone and was operational as evidenced by LPA dialing the number. The phone number designated for the facility is 760-488-1538.

Pre-Licensing and Component III are complete and facility is ready for licensure.

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

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

LIC809 (FAS) - (06/04)

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