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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603952
Report Date: 02/22/2022
Date Signed: 02/22/2022 03:01:48 PM


Document Has Been Signed on 02/22/2022 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:PROSPECT MANORFACILITY NUMBER:
197603952
ADMINISTRATOR:LYDIA PABIONFACILITY TYPE:
740
ADDRESS:800 PROSPECT AVETELEPHONE:
(626) 799-1141
CITY:SOUTH PASADENASTATE: CAZIP CODE:
91030
CAPACITY:99CENSUS: 45DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lydia Pabion - Administrator TIME COMPLETED:
03:15 PM
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Licensing Program Analyst(s) (LPA) Mary Flores and Jewel Baptiste conducted an annual inspection visit at the facility with focus on the infection control domain, food and medication review. LPAs Flores and Baptiste met with Lydia Pabion administrator and explained the reason for the visit.

Facility is licensed to served 99 adults over the age of 60 years old, of which 35 may be non-ambulatory. Facility has a hospice waiver for 4 and the following rooms are cleared for bedridden residents; 102 thru 110, 115 thru 119, and 123. Facility is a two story building with a commercial kitchen, a dining room, an activity room, a courtyard, a medication room, and front porch. No large bodies of water were observed. Sprinkler fire system throughout the facility. Fire extinguishers in hallways in each floor.

LPA Baptiste conducted a walk through of the facility with Jose DeLeon - Maintenance around 12:10pm and observed the following: Kitchen area has sufficient food worth 2 days of perishables and 7 days of non-perishables. All bedrooms have sufficient lighting, furniture, and all required bedding. Bathrooms were observed with skid matts and grab bars. Water temperature was tested in bathrooms for rooms #104,108,114, 209,216, and 223 between 105.5- 117.1 degrees F, which is within the required 105-120 degrees F. LPA observed supplements (tums/vitamins) in room #114. Facility is currently following COVID-19 recommendations, signs were posted through out the facility, bathroom was observed with soap, signs and paper towels. Screening is conducted for clients, staff and visitors. LPA observed enough PPE supplies for at least 30 days. N95 fit testing has been conducted for all staff. All staff are wearing face mask. LPA Flores conducted a review of files and medication around 12:15pm for Resident #1,#2,#3,#4,#5 and staff files #1,#2,#3,#4, #5. Administrator certificate was observed for Lydia Pabion #6006152740 expiration date: 8/10/23.
A technical violation was given during this visit. No deficiencies were noted.
Exit interview was conducted with Lydia Pabion administrator and a copy of this report and technical violation was given.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2022
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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