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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602925
Report Date: 01/16/2025
Date Signed: 01/17/2025 07:26:15 AM

Document Has Been Signed on 01/17/2025 07:26 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ARBOR VISTAFACILITY NUMBER:
197602925
ADMINISTRATOR/
DIRECTOR:		COMMODORE, KIMFACILITY TYPE:
740
ADDRESS:811 E WASHINGTON BLVDTELEPHONE:
(626) 797-7296
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 69CENSUS: 61DATE:
01/16/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Kim Commodore, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Vaid conducted an unannounced Case Management Health Checks visit regarding the evacuation of the residents from Bella Vista Lincoln facility. Administrator stated that on 1/13/25, facility at Arbor Vista 811 E Washington Blvd, Pasadena 91104. License # 197602925 started to receive eleven (11) residents/clients from Bella Vista Lincoln a licensed facility, 2612 N Lincoln Ave, Altadena 91001. Additionally, to conduct a health and checks visit regarding the Eaton fire incident on the relocation of (11) residents from facility Bella Vista at Lincoln, 2612 N. Lincoln Ave., Altadena, CA. 91001 - License # 198602253 to Arbor Vista 811 E Washington Blvd., Pasadena, CA. 91104 - License # 197602925 on 1/13/25. LPA met with Administrator, Kim Commodore and explained the purpose of the visit.

During the visit, LPA Vaid conducted a health and safety check and no concerns observed. LPA reviewed and obtained the resident and staff rosters. Per interview with the Administrator eleven (11) residents of Bella Vista Lincoln relocated to the facility on 01/13/2025. (4) resident is still with family members and are expected to be back in the facility by the end to the weekend. LPA toured the facility, inspected random residents' bedrooms and bathrooms. LPA observed kitchen to be clean and orderly. Facility was offering bottled water as the tap water is undrinkable until 01/14/25. LPA interviewed random residents and indicated that they are aware and were instructed not to use tap water. Facility is now okay to use tap water as per Fire Advisory. The facility has sufficient beds, hygiene supplies, beddings, linens, and everyone has a designated room. The kitchen has sufficient two-day perishable and seven-day non-perishable food supplies. The kitchen staff will be serving food using plates and utensils. Administrator posted signs on the elevator and common areas to remind residents not to use/consume tap water, until 01/14/2025.

Medications, MARs, and files of the (11) residents that have been transferred to Arbor Vista in Pasadena were brought with them and stored in a secured place. All Bella Vista at Lincoln residents are fully ambulatory, use no assistive devices, and do not require any incontinent care. There is sufficient staffing available to provide care for residents. Five (5) staff from Bella Vista Lincoln have on the premises assisting the facility. ***Continued on LIC 809-C***.......
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ARBOR VISTA
FACILITY NUMBER: 197602925
VISIT DATE: 01/16/2025
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Per the Administrator, it has been verified that a routine fire inspection and testing was completed on 12/30/2024 and fire drill was conducted with staff on 12/18/2024.

Administrator has extra supply of masks and gloves. LPA informed the Administrator to reach out to CCL if any resources or assistance is needed.

An exit interview was conducted, and a copy of this report was provided to Administrator Kim Commodore.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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