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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603374
Report Date: 05/28/2024
Date Signed: 05/28/2024 03:07:27 PM

Document Has Been Signed on 05/28/2024 03:07 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/
DIRECTOR:
ELIZABETH NADEAUFACILITY TYPE:
775
ADDRESS:3740 E. SIERRA MADRE BLVD.TELEPHONE:
(626) 351-5427
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 26CENSUS: 16DATE:
05/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Alba Rangel - Program Room AideTIME VISIT/
INSPECTION COMPLETED:
03:21 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with and explained the reason of 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 Alba Rangel and observed the following:
Program Room is clean a total of 16 adults were observed in the room doing activities. Facility stores materials for activities throughout their storage space. Kitchenette area was observed clean. Cleaning supplies were observed under the sink inaccessible to adults in care. Sharps are stored inaccessible to adults in care to the left of the refrigerator in a cabinet. Refrigerator is only to stored snacks. Meals are delivered to the facility. First Aid kit was reviewed. Facility maintains a bin with emergency food supplies. Smoke detectors were observed in the classroom and last checked on 5/7/24 by staff. Fire extinguisher was observed by the door and checked on 5/7/24. Outside area is clean with a fence surrounding it and provides a shaded seating area. Emergency Drill was conducted on 5/7/24.

Facility does provide assistance with medication. However, none of the clients are being provided medications at this time.

LPA Flores reviewed 5 client files and 5 staff files. Emergency Disaster Plan was reviewed and last checked on 5/2/24. Infection Control Plan was reviewed.

No Deficiencies were noted during this visit.
Exit interview was conducted with Elizabeth Nadeau and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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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