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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603952
Report Date: 06/09/2021
Date Signed: 06/09/2021 10:32:24 AM

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: 46DATE:
06/09/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:Lydia Pabion - Administrator TIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst(s) Mary Flores and Nina Galarza conducted a case management visit to follow up on incident report dated 6/4/21 which reported smoke on the facility.

During the visit LPA(s) conducted a tour with Lydia Pabion administrator of the kitchen to ensure facility has sufficient food of 2 days of perishables and 7 days of non-perishables, toured room #121 were the smoke was reported. Room #121 was evacuated and resident #1(R1) who was staying in the room was moved to room 119 as the area is being repair. LPA(s) tour room #229 above room #121 to ensure there was no signs of fire in the room. Room #229 is kept as a storage room and 2 oxygen tanks were observed, administrator stated they were to be disposed but has not and will disposed of them on 6/9/21. Facility is to follow regulation 87618 to properly disposed of oxygen tanks. LPA(s) did not observed fire debris, smoke was still breathable in room #121. Debris outside the corner of the building was observed and a contractor was hired on 6/4/21 to begin repairs of concrete pull by fire department to find the source of smog. Fire department' report states "The source of the smoke was a smoldering structural member on the Alpha Delta corner. The smoldering fire was extinguished with a 2.5 gallon water extinguisher. After knockdown residents on the second floor were cleared to repopulate." Residents are at the facility, staff is providing care. LPA(s) were provided with a copy of the report.

Deficiencies will be cited per Title 22 Division 6 Chapter 8 on LIC 809D.

Exit interview was conducted with Lydia Pabion administrator and a copy of this report, LIC 809D, appeal rights were provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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: PROSPECT MANOR
FACILITY NUMBER: 197603952
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2021
Section Cited

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87618 Oxygen Administration: (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (I) Equipment shall be removed from the facility when no longer in use by the resident.
This requirement is not met as evidence by:
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Based on observation during facility's tour LPA(s) observed two oxygen tanks in room #229 kept as storage above room#121 were a smoldering fire occured on 6/4/21 which poses an immediate health, safety, or personal rights risk 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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2021
LIC809 (FAS) - (06/04)
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