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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603952
Report Date: 06/19/2023
Date Signed: 10/10/2023 05:34:01 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/10/2023 05:34 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 MANORFACILITY NUMBER:
197603952
ADMINISTRATOR:LYDIA PABIONFACILITY TYPE:
740
ADDRESS:800 PROSPECT AVETELEPHONE:
(626) 799-1141
CITY:SOUTH PASADENASTATE: CAZIP CODE:
91030
CAPACITY:99CENSUS: 52DATE:
06/19/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lydia PabionTIME COMPLETED:
11:00 AM
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This is a corrected version of previous Annual Visit dated 01/28/23. LIC 809-D page was amended to correct deficiency from "Type A" to "Type B" for 87303(e)(2) only.
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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
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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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: 06/19/2023
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Resident rooms 1st 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 2nd 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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/10/2023 05:34 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: 06/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2023
Section Cited
CCR
87303(e)(2)

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(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:
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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.
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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.
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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: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/10/2023 05:34 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: 06/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2023
Section Cited
CCR
87303(e)(3)

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(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:
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Licensee/Administrator will place a warning signs above kitchen sinks where water temperature will be delivering water at 125 degree F or above.
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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.
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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: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
LIC809 (FAS) - (06/04)
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