198603655-7-14-2023-28-AS-BTAO-CTQQF6-20230714120727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603655
Report Date: 07/14/2023
Date Signed: 07/14/2023 12:07:52 PM

Document Has Been Signed on 07/14/2023 12:07 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ALTA VISTA CARE HOME		FACILITY NUMBER:	198603655
ADMINISTRATOR:	ENRIQUEZ,ALMA/STINSON,NICO		FACILITY TYPE:	740
ADDRESS:	5349 N. OAKBANK AVE.		TELEPHONE:	(626) 587-0088
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY: 6		CENSUS: 0	DATE:	07/14/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Alma Enriquez, Applicant		TIME COMPLETED:	12:00 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) Tao conducted an announced pre-licensing inspection. This is an initial application applying for Residential Care for Elderly to serve residents for age 60 and above. LPA met with Alma Enriquez, applicant. The requested capacity is six (6). Fire clearance approved for six (6) non-ambulatory residents. Hospice waiver was approved for six (6). Advertising dementia special care program was submitted with application. No resident and no staff at the time of visit. Fire clearance: Fire clearance was granted on 04/18/23 for six (6) non-ambulatory and zero (0) bedridden. Fire clearance is in place. Dementia care plan was submitted. Auditory devices are installed at all exits and operational. Structure: The property is a single-family residence located in a neighborhood, consist of six (6) bedrooms, four (4) bathrooms, kitchen, dining room, living room with TV, laundry room, storage room, and administrative area. Passageways, walkways and patios are free from obstructions. The entrance and side areas are free of hazards and debris. Signal system and Garage: Facility does not have a signal system. Garage is not accessible to residents. (- Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALTA VISTA CARE HOME	FACILITY NUMBER: 198603655
	VISIT DATE: 07/14/2023

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
26
27
28
29
30
31
32

Bedrooms for Residents:
Bedrooms have nightstand, adequate lighting, adequate closet and drawer space. Bedrooms are spacious and allow for easy passage between and comfortable for usage.

Bathrooms:
Toilet, wash basin, bathtub/shower in bathrooms are operable. Bedrooms are accommodated for residents. Grab bars are maintained for each toilet, bathtub and shower.

Linens & Hygiene Supplies:
Sufficient linen/supplies which include pillowcases, mattress pads, blanket and bedspreads are available. Adequate supply of linen, wash cloths and towels are observed.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Dishwasher in kitchen properly installed and functioning. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet in the kitchen and inaccessible to residents. Food supply consist of two days of perishable and two weeks of non-perishable was observed.

Medications, First-Aid Kit & Book:
Medication cabinet is installed with a key lock and inaccessible to residents. First aid kit has a thermometer, tweezers, scissors, antiseptic, bandages, and gauze.

Smoke Detectors:
Dual Smoke /carbon monoxide detectors are tested and operable. They are located in common areas and each bedroom.

(-Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALTA VISTA CARE HOME	FACILITY NUMBER: 198603655
	VISIT DATE: 07/14/2023

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
26
27
28
29
30
31
32

Appliances:
Stove burners, oven, microwave, washer, and dryer were operational. Refrigerator is located in the kitchen and measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat.

Toxins:
Poisons, toxins, and cleaning supplies are locked and inaccessible to residents. They are stored separately from food source.

Emergency Phone Numbers, Exit Plan, Signages and posters:
Emergency Disaster Plan and Labor law poster are posted. Exit Plan are available for review.

Outdoor activity area in backyard:
Outdoor activity area is furnished with chairs and table and in compliance. Shaded area in the backyard at the outdoor activity area is provided.

Residents & Staff Files:
Key lock cabinets for records of staff and residents are installed and available. Applicant will not handle cash resources for residents.

Water Temperature:
Tested at 110.1 degrees Fahrenheit.

Menu and phone:
Menus are available for review. Free landline telephone is available for residents’ use and operable.

(- Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALTA VISTA CARE HOME	FACILITY NUMBER: 198603655
	VISIT DATE: 07/14/2023

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
26
27
28
29
30
31
32

Fire extinguishers:
Fire extinguisher is available in the facility and is new.

Pool:
No bodies of water located at the facility.

Finding:
No issue was observed during today’s visit.

Exit:
Component III Orientation was conducted during this visit.

A copy of this report was provided to applicant. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, s/he has been instructed to communicate with the CAB Analyst who assigned to his/her application.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4