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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603374
Report Date: 08/19/2021
Date Signed: 08/30/2021 11:12:26 PM

Document Has Been Signed on 08/30/2021 11:12 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:COMMUNITY ASSISTANCE PROGRAM FOR SENIORSFACILITY NUMBER:
197603374
ADMINISTRATOR:MILDRED BROWNFACILITY TYPE:
775
ADDRESS:3740 E. SIERRA MADRE BLVD.TELEPHONE:
(626) 351-5427
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 26CENSUS: 8DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Elizabeth Nadeau, AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Linda Almaraz conducted an annual required visit. LPA met with Administrator, Elizabeth Nadeau and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents emergency contacts, and food service. Facility has submitted a mitigation plan and is approved. Facility serves 26 non-ambulatory clients, ages 55 and over. During the visit, 8 clients were present.

LPA toured the facility inside and out to include administrative office and large activity room.
Meals are not prepared at the day program. Meals are prepared off-site and brought to the program daily and served to the clients. Per Administrator, a catering company delivers lunch everyday. The facility provides snacks to the clients. Hot water temperature was measured at 112.3 degrees Fahrenheit in client bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. There are no bodies of water on the premises. LPA reviewed training records for staff and PPE supply. Emergency Kit and Emergency food supply was checked. Designated isolation room was also inspected.

No deficiencies cited. An exit interview was conduct with the Administrator and a hard copy was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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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