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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881223
Report Date: 10/18/2024
Date Signed: 10/18/2024 05:36:07 PM

Document Has Been Signed on 10/18/2024 05:36 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ARYA SENIOR CARE HOMEFACILITY NUMBER:
361881223
ADMINISTRATOR/
DIRECTOR:		IMTIAZ, KANWALFACILITY TYPE:
740
ADDRESS:18554 OLALEE WAYTELEPHONE:
(626) 241-4585
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 6DATE:
10/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Sarabjeet Singh- StaffTIME VISIT/
INSPECTION COMPLETED:
05:54 PM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Sarabjeet Singh introduced self and stated purpose of the visit. LPA was informed that there are currently 6 residents in care who are in the facility.

The facility has (5) resident bedrooms, (3) resident bathrooms, living room, family room, (2) dining areas, kitchen, pantry, laundry room, office, backyard, and attached garage. LPA completed a walk through of facility and review of records.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 105.7 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguishers and first aid kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications were observed secured and inaccessible to residents. There are no guns, ammunition, swimming pool or bodies of water in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
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 SENIOR CARE HOME
FACILITY NUMBER: 361881223
VISIT DATE: 10/18/2024
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Yards/Outside: One shaded patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA discovered through interview that the Administrator did not have on file a report sent to the local fire jurisdiction for oxygen used in the facility. Technical violation issued. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed through record review that disaster drills were not conducted for each shift. Technical violation issued.

No deficiencies and two technical violations were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, and LIC9102TV were discussed and copies were provided to Administrator, Kanwal Imtiaz who arrived later.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC809 (FAS) - (06/04)
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