197603952-1-28-2023-28-AS-KRAZ-CNHSTX-20230128131016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603952
Report Date: 01/28/2023
Date Signed: 01/28/2023 01:10:35 PM

Document Has Been Signed on 01/28/2023 01:10 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:	PROSPECT MANOR		FACILITY NUMBER:	197603952
ADMINISTRATOR:	LYDIA PABION		FACILITY TYPE:	740
ADDRESS:	800 PROSPECT AVE		TELEPHONE:	(626) 799-1141
CITY:	SOUTH PASADENA	STATE: CA	ZIP CODE:	91030
CAPACITY:	99	CENSUS: 51	DATE:	01/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Activites Director Roxana Deleon		TIME COMPLETED:	01:30 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required Annual Visit on 01/28/2023 at 9:25 am. LPA was met by Licensed Vocational Nurse (LVN) Gloria Madrid and Activities Director Roxana Deleon. Administrator Lydia Pabion was notified by phone of LPA’s visit. LPA requested and obtained a copy of Personnel Report (LIC 500), Resident Roster (LIC 9020) and copy of Liability Insurance.

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, 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 were observed to fully charged.

LPA OBSERVATIONS: Tour was given by LVN Madrid at 9:40 am.

TV Room: was clean and had sufficient seating and tables.

Kitchen: Staff was observed to be wearing masks, hair nets and gloves while preparing lunch for residents. LPA observed kitchen to be clean and appliances appeared to be in working order. Walk in refrigerator was observed to contain sufficient food supply for 2 days of perishables and 7 days of non-perishables and a temperature reading of 40 degrees F. Walk in freezer was clean and a temperature reading of 0 degrees F. Kitchen sink water temperature was measured at 184.1 degrees F. No warning sign posted above this sink or any other kitchen sink in kitchen area was observed. Signs promoting hand washing and social distancing were observed.

Dining Room: Dining room area was clean, and tables were spaced out to promote social distancing. Signs promoting social distancing and cough/sneeze etiquette were observed throughout dining area. LPA observed a corner area of dining room to have several stacked dining room chairs, rectangle bbq grill, empty grocery cart, 4ft standing fan, boxed Christmas tree, and a beige serving cart to be cluttered in the corner of the room. Per LVN Madrid, the facility is using this area to store excess chairs until they can find another place to store them.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

Document Has Been Signed on 01/28/2023 01:10 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: PROSPECT MANOR	FACILITY NUMBER: 197603952
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, resident room #108 water temperature read at 99.8 degrees F, resident room #201 water temperature read at 96.8 degrees F, resident room #209 water temperature read at 95.4 degrees F, resident room #220 water temperature read at 99.1 degrees F, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/29/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will adjust water heater accordingly and create a water log starting 01/29/2023 and record water temperature readings every 8 hours for the next 3 calendar days, ending on 02/01/2023. Licensee/ Administrator will send proof of water temperature log to LPA via email. First record of water log on 01/29/23 and subsequent recorded readings must measure within 105 -120 degress F.

Type A

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, water temperature in kitchen was measured at 184.1 degrees F, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/29/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will place a warning signs above kitchen sinks where water temperature will be delivering water at 125 degree F or above.

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	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 01/28/2023 01:10 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: PROSPECT MANOR	FACILITY NUMBER: 197603952
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, resident room #108 wall located behind nightstand has 3 x 9 hole and is exposing dry wall and cement, bathroom cabinet door is cracked and knobs are missing, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/03/2023
	Plan of Correction
1 2 3 4	Licensee/Adminstrator will repair hole and replace or reapair cabinet. Photo proof is required and must be submitted to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: PROSPECT MANOR	FACILITY NUMBER: 197603952
	VISIT DATE: 01/28/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Resident rooms 1^st floor Non-Ambulatory: Rooms # 101 and 104 contained the required lighting, furniture, and linens. Water temperature in Room # 101-bathroom was measured at 106.2 degrees F and room # 104 water temperature in bathroom was measured at 107.8 degrees F which meets Title 22 Regulations. Room #108 is a shared room. Room #108 contained required lighting, furnishings, and linens. Bathroom contained skid matts and grab bars. Water temperature was measured at 99.8 degrees F which is does not meet Title 22 Regulations and poses an immediate health, safety, or personal rights risk to persons in care. Cabinet doors in bathroom are missing knobs and right cabinet door is cracked from top to the side of door.

Resident rooms 2^nd floor Ambulatory: Resident room # 201 contained required lighting, furnishings, and linens. Room was clean and LPA observed hand sanitizer nearby. Water temperature in bathroom was measured at 96.8 degrees F which does not meet Title 22 Regulations. Resident room # 209 contained required lighting, furnishings, and linens. Room was observed to be clean. Water temperature in bathroom was measured at 95.4 degrees F which does not meet Title 22 Regulations. Resident room # 220 contained required lighting, furnishings, and linens. Room was observed to be clean. Water temperature in bathroom was measured at 99.1 degrees F which does not meet Title 22 Regulations. Resident room # 223 contained required lighting, furnishings, and linens. Room was observed to be clean. Water temperature in bathroom was measured at 110.4 degrees F which meets Title 22 Regulations.

Front lobby and Courtyard: Clean and free from hazards and clutter. LPA observed plenty of seating, tables and shade for residents and visitors.

Staff and Resident Interviews: 3 staff and 3 residents were interviewed between 10:45 am and 11:15 am.

Administrator certificate was observed for Lydia Pabion #6006152740 expiration date: 8/10/23. Last fire drill was conducted on 01/2023.

A technical violation and deficiencies were cited during visit. Exit interview was conducted with Activities Director Deleon and a copy of this report, LIC 809D, LIC 9102, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5