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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603739
Report Date: 08/16/2022
Date Signed: 08/17/2022 08:25:23 AM

Document Has Been Signed on 08/17/2022 08:25 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:MENTONE HOUSEFACILITY NUMBER:
197603739
ADMINISTRATOR:ROBIN PHILLIPSFACILITY TYPE:
735
ADDRESS:1980 MENTONETELEPHONE:
(626) 398-5629
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 6DATE:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator / Magdalena "Maggie" EstradaTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with one to one Staff / Jen Raymond for Client #1 (C1) and was later joined by Administrator / Magdalena "Maggie" Estrada who assisted with the visit. The facility is licensed to serve six (6) Developmentally Disabled Clients ages 18 - 59 years. The facility has an approved fire clearance for six (6) Ambulatory Clients only. Currently, there are six (6) clients in placement. LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed.

The facility is located in a residential area. A tour of the single-story facility includes: Four (4) client bedrooms, two (2) bathrooms, living room, kitchen, dining area, den/staff office and indoor/outdoor activity areas. All medications for residents who need assistance are kept locked and inaccessible to other residents.

The bathrooms are clean and operational. Client bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The hot water temperature was tested throughout the facility. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured cabinet and inaccessible to clients. The first-aid kit is fully stocked w/First-aid Manual. LPA reviewed client medications.

Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed to be fully charged and in compliance. There is a functioning telephone on the premises. The facility has central AC and heating accommodations. The washer and dryer are located in the laundry area (near the kitchen). The front yard is well landscaped with steps and/or a ramp that leads to the entry. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris and
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MENTONE HOUSE
FACILITY NUMBER: 197603739
VISIT DATE: 08/16/2022
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the trash cans have covered lids. There are no security bars or weapons on the premises. There is no evidence of bodies of water (pool) on the premises. There is a detached two-car garage which is kept locked and inaccessible to clients.

During today's walk through, LPA observed COVID-19 prevention/protocol signs posted throughout the facility.

The following concern was observed during today's visit;

  • At 2:15pm, the hot water temperature in bathroom 1 was measured at 100.2 degrees F. At 2:17pm, the hot water temperature in bathroom 2 was measured at 99.7 degrees F. At 2:27pm, the hot water temperature in the kitchen was measured at 104.8 degrees F.

The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)

An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/17/2022 08:25 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 08/16/2022 at 02:40 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: MENTONE HOUSE
FACILITY NUMBER: 197603739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2022
Section Cited

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Furniture, Fixtures, Equipment, and Supplies.
Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients 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).
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This requirement is not met as evidenced by:
At 2:15pm, the hot water temperature in bathroom 1 was measured at 100.2 degrees F. At 2:17pm, the hot water temperature in bathroom 2 was measured at 99.7 degrees F. At 2:27pm, the hot water temperature in the kitchen was measured at 104.8 degrees F.
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


LIC809 (FAS) - (06/04)
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