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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006494
Report Date: 06/13/2024
Date Signed: 06/13/2024 11:04:45 AM

Document Has Been Signed on 06/13/2024 11:04 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SIERRA VISTA SENIOR LIVINGFACILITY NUMBER:
306006494
ADMINISTRATOR/
DIRECTOR:		ARIAS, ALEXANDERFACILITY TYPE:
740
ADDRESS:1763 S CARNELIAN STTELEPHONE:
(832) 386-9747
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: DATE:
06/13/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Alexander AriasTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Administrator/ Licensee Alexander Arias. An initial application to operate a Residential Care Facility for the Elderly was received by CCL on 01/23/2024 for a capacity of six non-ambulatory residents. Facility has a screening area in the entrance of the facility.
LPA Lyman along with Licensee/ Administrator toured the facility at 9:07 AM and observed the following:
Structure: Facility is a one story, 4 bedroom, 2 bathroom house with a bonus room and an unattached garage and a tan exterior. The exit gates are closed, self latching, alarmed and unlocked. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms will be single and double occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Facility has sanitizer and paper towels in the restrooms. Linens & Hygiene Supplies: Facility has ample bedding and towels for residents in care. Emergency Phone Numbers and Exit Plan: Posted in the entrance of the facility. Food Service: Facility has 2 day perishables as well as 7 day non-perishables. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguisher is mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Facility has multiple secured areas for toxins and sharps. Water Temperature: Tested and recorded between 126.6 and 137.2 degrees F. in facility bathrooms. Emergency Supplies: LPA observed ample emergency food as well as a posted emergency disaster plan. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. Medication is stored and locked in a locked cabinet. CONTINUED ON LIC 809C DATED 06/13/2024
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SIERRA VISTA SENIOR LIVING
FACILITY NUMBER: 306006494
VISIT DATE: 06/13/2024
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Facility to use use a medication administration record. Resident & Staff File: Records are stored in a secured file cabinet in the kitchen. Reading Material, Games, and Equipment: LPA observed activities such as games and reading supplies. Facility provides exercise and music therapy..Backyard: LPA observed a clean backyard with ample shaded seating for residents. Fire Clearance: Approved for six non-ambulatory residents on 04/12/2024.

During the visit, LPA observed the following:
  • Facility does not have fireplace screened. Please obtain a screen.
  • There is not a working telephone on site. Please ensure there is a telephone.
  • Facility does not have night lights in hallway. Please ensure night-lights are installed.
  • Water temperature is out of compliance. Please adjust.
  • Facility does not have ample emergency water. Please obtain additional water.
  • Please post the "Let Us No" poster size 20" X 26"
  • Please reconfigure bedroom 4 to ensure no doors are blocked and all required furnishings fit.
  • Please obtain dressers for


Component III conducted during the visit. Facility is not ready to be licensed. Licensee to contact LPA when corrections have been made.


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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