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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222713
Report Date: 03/02/2022
Date Signed: 03/02/2022 02:50:36 PM


Document Has Been Signed on 03/02/2022 02:50 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:PASA ALTA WESTFACILITY NUMBER:
191222713
ADMINISTRATOR:DEWALT BROWNFACILITY TYPE:
740
ADDRESS:1773 N. FAIR OAKSTELEPHONE:
(626) 398-9110
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:6CENSUS: 5DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Assistant Administrator / Steven "Shay" JamesTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted a site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Assistant Administrator / Steven "Shay" James who assisted with the visit. The facility is licensed to serve six (6) ambulatory adults 60 years of age or older with developmental disabilities. Currently, there are five (5) residents in placement. The facility does not have an approved Hospice Waiver. The facility does not have an approved Dementia Care plan in its plan of operation and does not accept residents with dementia. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed.

The facility is vendorized by the Frank D. Lanterman Regional Center, Level 3 home. The facility is located in a residential / commercial area. A tour of the single-story facility includes: three (3) resident bedrooms, two (2) resident bathrooms, one (1) staff bedroom with its own private one (1) bathroom, living room, dining room, laundry room, kitchen and indoor/outdoor activity areas.

All medications for residents who need assistance are kept locked and inaccessible to other residents. Knives, disinfectants and cleaning solutions are kept locked and inaccessible to residents. The bathrooms are clean and operational. Resident bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested throughout the facility. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. LPA reviewed resident medications.

Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers (2) were fully charged and in compliance. The first-aid kit is fully stocked w/First-aid Manual. The front yard is well landscaped with steps and/or a ramp that leads to the entry. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. The trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars nor
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASA ALTA WEST
FACILITY NUMBER: 191222713
VISIT DATE: 03/02/2022
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weapons on the premises.

The following deficiency was observed during today's visit;
  • At 12:38pm, the hot water temperature in the kitchen was measured at 125.5 degrees F. At 12:52pm, The hot water temperature in bathroom #2 was measured at 125 degrees F.

The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/02/2022 02:50 PM - It Cannot Be Edited

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: PASA ALTA WEST
FACILITY NUMBER: 191222713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2022
Section Cited

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Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less
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than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by: At 12:38pm, the hot water temperature in the kitchen was measured at 125.5 degrees F. At 12:52pm, The hot water temperature in bathroom #2 was measured at 125 degrees F. This poses an immediate health, safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
LIC809 (FAS) - (06/04)
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