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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222713
Report Date: 02/11/2023
Date Signed: 02/11/2023 01:02:32 PM


Document Has Been Signed on 02/11/2023 01:02 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
GREATER LA AC/SC, 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: 6DATE:
02/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Administrator, Staci D. MitchellTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Pena was greeted by Ralph Ruelas, Direct Support Professional I (DSP I) and discussed the purpose of today's visit. The facility is cleared for six (6) ambulatory, prefers to serve elderly clients with developmental disabilities. There are currently 6 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. The facility is vendorized by the Frank D. Lanterman Regional Center and Northern California Regional Center.The Administrator, Staci D. Mitchell arrived at 10:35am and assisted with the inspection. This single-story home contains four (4) bedrooms including office/staff room, three (3) bathrooms, living room, kitchen, dining room and backyard.

The following was observed/inspected:
  • The facility had a universal entrance screening area including a sign-in sheet, thermometer, and hand sanitizer. Staff/DSP did not conduct covid screening to the LPA upon arrival and has to be prompted.
  • COVID-19 signage was placed in several areas including entrance and common areas.
  • Facility does not have a 30-day supply of PPEs, supplies are insufficient.
  • Staff was not wearing face masks during their shift.
  • Kitchen was inspected. There was a sufficient supply of 2-day perishable foods and 7-day non-perishable foods.
  • Cleaning solutions and kitchen knives/sharps were not locked and accessible to the residents.
  • Hot water temperature was measured and were within the required 105-120 degrees F., kitchen hot water temperature read 113.9 deg F, bathroom #1 read 115.8 def F and bathroom #2 read 113.4 deg F.
  • All resident rooms contained required furniture including bed, dresser, night stand, lamp and chair.
  • Medications were locked and centrally stored in the upper cabinet in the kitchen area. Residents' medications were reviewed to confirm medication is given as prescribed and is documented properly.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • There are cameras in the living room, kitchen, front/backyard, and around the outside of the home. There were no cameras seen in private areas.
  • Indoor passageways were free from obstruction. But outdoor passageways contain debris and unused items.
  • Two (2) fire extinguishers were observed to be charged and last serviced on 2/18/2022 and 5/18/2022. Administrator was advised to get those inspected soon.
  • Residents and Staff files were not reviewed during this visit.
  • Administrator certificate for Staci D. Mitchell expires on 1/20/2024 and DeWalt Brown expires on 10/15/2024..

Pursuant to Title 22, deficiencies were cited on the attached 809D. An exit interview was conducted and a copy of this report and appeal rights were provided to the Administrator, Staci D. Mitchell.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2023
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


Document Has Been Signed on 02/11/2023 01:02 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
GREATER LA AC/SC, 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: 02/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the Administrator did not comply with the section cited above in that disinfectants/cleaning solutions were observed to be unlocked in the kitchen cabinet under the sink. Additionally, few kitchen knives and sharp objects were also observed in one of the kitchen cabinets unlocked and accessible to the residents which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2023
Plan of Correction
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Administrator will submit photos that kitchen cabinets have locks and shall conduct staff training regarding the potential dangers of having unlocked disinfectants, cleaning solutions, and other dangerous items accessible to clients in care. Submit a written plan of correction stating how this deficiency was corrected on or before the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/11/2023 01:02 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
GREATER LA AC/SC, 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: 02/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in that LPA observed debris and unused items around the yard and in the outdoor passageways which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2023
Plan of Correction
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Administrator will submit photos/proof that the outdoor passageways and backyard have been organized and clean and free of debris and will submit plan of correction to CCLD on or before the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 02/11/2023 01:02 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
GREATER LA AC/SC, 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: 02/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87470(c)(1)(F)
Infection Control Requirements. Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observation and interview, the Administrator did not comply with the section cited above in which LPA was greeted by Staff/DSP I inside the facility (by the front door) and Staff/DSP I was observed not wearing a face covering/mask, while working inside the facility. Another staff who works for a 3rd party vendor was also observed not wearing a face covering/mask. Also, Staff did not conduct covid screening to the LPA upon entry and had to be prompted. LPA also observed that facility has insufficient supplies of PPEs which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2023
Plan of Correction
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Administrator will send photos/receipts of additional PPE supplie ensure that all facility staff are following Pasadena Public Health and CCLD requirements by conducting an in-service training with all staff on the importance of wearing a face covering/mask and also on the importance of COVID screening for all visitors, staff and residents. Administrator will send photos/receipts of additional PPE supplies and submit a copy of the sign-in sheet of all attendees along with the topics covered during the in-service training to CCL by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4