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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603680
Report Date: 06/06/2023
Date Signed: 06/06/2023 02:01:57 PM


Document Has Been Signed on 06/06/2023 02:01 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:HAMPTON GUEST HOME, INC.FACILITY NUMBER:
197603680
ADMINISTRATOR:YANG, ERLINDAFACILITY TYPE:
740
ADDRESS:3790 HAMPTON RD.TELEPHONE:
(626) 351-1215
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 6DATE:
06/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Jeffrey Yang - Assistant AdministratorTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted a case management visit at the facility to give deficiencies found during a complaint investigation. LPA met with Jeffrey Yang and explained the reason for the visit.

During file review for a complaint investigation conducted on 6/6/23, LPA discovered annual medical assessment for resident #1(R1) was last conducted on 4/26/19. Per Title 22 Regulations residents with dementia are to have an annual assessment.

The facility failed to obtain an annual medical assessment for R1. Therefore, deficiencies are being noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
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 06/06/2023 02:01 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: HAMPTON GUEST HOME, INC.
FACILITY NUMBER: 197603680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2023
Section Cited
CCR
87705(c)(5)

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Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall...: (5) ... have an annual medical assessment as specified in Section 87458, Medical Assessment,... done at least annually...
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Administrator will ensure to conduct annual medical assessments for residents with dementia and will certify this on a LIC 9098,
and will submit current residents medical assessments to the department by POC due date 6/13/23.
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This requirement is not met as evidence by:
Based on documents review licensee failed to obtain an annual medical assessment for R1 which poses a potential risk to the health, safety, or personal rights to the persons in care.
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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 VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
LIC809 (FAS) - (06/04)
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