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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006494
Report Date: 06/06/2025
Date Signed: 06/06/2025 12:20:42 PM

Document Has Been Signed on 06/06/2025 12:20 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
ORANGE COUNTY RO, 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: 4DATE:
06/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Alexander Arias (Administrator) TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) William Vanegas made an unannounced inspection for the purposes of conducting an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry by Care Giver (CG) Martin Jose. LPA Vanegas began to set up equipment, began a tour of the facility, and observed the following.

This is a one storied home with four bedrooms, two bathrooms, and a one car detached garage. LPA Vanegas observed the kitchen area to be clean and free of any mildew. LPA Vanegas observed a refrigerator, microwave, dishwasher, gas stove, washer, and dryer. All appliances appeared to be in good repair, and tested to be operational. LPA Vanegas observed a two day supply of perishable food, and a seven day supply of non-perishable food, along with a sufficient amount of emergency water.

LPA Vanegas observed all resident rooms to be clean and free of any debris. LPA Vanegas observed the bedrooms to have all required furnishings such as a bed, clean linens in good repair; meaning no strains or tares, chest drawer, a reading lamp, and enough storage space to store personal belongings.

LPA Vanegas observed resident bathrooms to have all required furnishings such as grab bars, shower chair, and slip resistant floor matts. LPA Vanegas observed bathroom water faucets and toilets to be operational, and in good repair. Water tested between 119.8 and 125.3 degrees. LPA Vanegas observed all fire extinguishers to be fully charged and up to date. LPA Vanegas observed all smoke detectors and carbon monoxide detectors to be in good repair and operational.

CONTINUED ON LIC809C
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SIERRA VISTA SENIOR LIVING
FACILITY NUMBER: 306006494
VISIT DATE: 06/06/2025
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LPA Vanegas observed first aid kit to have all required items such as adhesive tape, tweezers, scissors, bandages, a thermometer, and a first aid manual. LPA Vanegas observed the backyard to be big enough to participate in outdoor activities upon resident request. LPA Vanegas observed there to be an outdoor shadded sitting area, and no obstructions along the exit routes. LPA Vanegas observed side doors to be self latching and unlocked.

LPA Vanegas reviewed four resident files, and four staff files. All files (Staff and Resident) had all required documents and annual training was completed for all staff. LPA Vanegas reviewed medication administration record (MAR), and resident medications. Per LPA review all medications are being documented correctly and administered per physicians orders.

Based on observations made during today's inspection no deficiencies will be cited per title 22 chapter 8 division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Alexander Arias and a copy of this report was provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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