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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603374
Report Date: 06/09/2022
Date Signed: 06/09/2022 10:56:08 AM

Document Has Been Signed on 06/09/2022 10:56 AM - 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: 10DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Morena Quijada - Program Room Aide
Elizabeth Nadeau - Program Director 		TIME COMPLETED:
11:15 AM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on the infection control domain, facility does not prepare meals or provide medication. LPA Flores met with Morena Quijada program room aide and explained the reason for the visit. Elizabeth Nadeau Program Director arrived 15 minutes later.

The facility is licensed as an Adult Day Care for Adults/Elderly ages of 55 and over for a capacity of 26 consumers. The facility has an approved fire clearance for 26 Non-Ambulatory clients. Facility is located in 1 large commercial building - the licensed program consist of an office, 1 storage room, 1 bathroom with multiple stalls, and a large program room which includes a kitchen area.

LPA Flores conducted a tour of the facility with Morena Quijada Program Room Aide and observed the following:
Client's bathroom has 4 stalls with toilets in working condition and grab bars in each stall, 2 sinks were observed and water temperature was tested in one sink at 107.4 degrees F., which is within the required 105-120 degrees F. Hand washing sign, soap, and paper towels were observed. Disinfecting supplies were observed in a lock cabinet. Storage room has sufficient PPE supplies for 30 days. Activity/kitchen area was observed sharps were locked in a cabinet to the left of refrigerator and cleaning/disinfecting supplies are kept locked under the sink. Screening area is located upon one central entry point of facility with log available for staff/clients, and screening questionnaire. Staff were observed wearing face masks. Meals are delivered to the facility and not prepared at the facility, LPA advice that social distancing be maintain during meals and activities. LPA reviewed 5 client files and 3 staff files. Smoke detector was tested and fire extinguisher was observed by the door and was last check on 8/21. Outdoor area was observed clean, free of debris and large bodies of water.
No deficiencies observed during this visit.
Exit interview was conducted with Elizabeth Nadeau Program Director and a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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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