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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603374
Report Date: 05/11/2023
Date Signed: 05/11/2023 03:01:58 PM

Document Has Been Signed on 05/11/2023 03:01 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:COMMUNITY ASSISTANCE PROGRAM FOR SENIORSFACILITY NUMBER:
197603374
ADMINISTRATOR:ELIZABETH NADEAUFACILITY TYPE:
775
ADDRESS:3740 E. SIERRA MADRE BLVD.TELEPHONE:
(626) 351-5427
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 26CENSUS: 14DATE:
05/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Elizabeth Nadeau - Administrator TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual inspection visit using the CARE inspection tool. LPA Flores met with Elizabeth Nadeau Administrator and explained the reason for the visit.

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 Elizabeth Nadeau Administrator and observed the following:
Facility's classroom is clean and in good repair. Smoke/Carbon monoxide detectors were tested and in working condition. Cleaning supplies and sharps were observed locked in cabinets in kitchenette area. A refrigerator was observed for snacks. Meals are delivered to the day program. Activities were observed. First aid kit, and emergency supplies were observed. Bathroom was observed in working condition with grab bars and water temperature was tested at 124.5 degrees F., which is not within the required 105-120 degrees F. Facility does not assist with medication. LPA interviewed 3 staff and 3 clients.

LPA reviewed 5 client files and 5 staff files, and emergency disaster plan. Facility's last fire drill was conducted on 5/5/23. Fire extinguisher was last checked on 9/12/22.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Elizabeth Nadeau Administrator and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2023
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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Document Has Been Signed on 05/11/2023 03:01 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/11/2023 at 02:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COMMUNITY ASSISTANCE PROGRAM FOR SENIORS
FACILITY NUMBER: 197603374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in water temperature tested in bathroom's sink at 124.5 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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Administrator will ensure water temperature is maintain within the required 105-120 degrees F. and certify on LIC 9098 by POC due date 5/12/23. Administrator will maintain a log of water temperature for the next seven days and submitted to the department by 5/18/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023


LIC809 (FAS) - (06/04)
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