197603952-1-21-2025-28-AS-MGFS-DD5TWC-20250121140519

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603952
Report Date: 01/21/2025
Date Signed: 01/21/2025 02:05:49 PM

Document Has Been Signed on 01/21/2025 02:05 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/ DIRECTOR:	LYDIA PABION		FACILITY TYPE:	740
ADDRESS:	800 PROSPECT AVE		TELEPHONE:	(626) 799-1141
CITY:	SOUTH PASADENA	STATE: CA	ZIP CODE:	91030
CAPACITY: 99	TOTAL ENROLLED CHILDREN: 0	CENSUS: 51	DATE:	01/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:43 AM
MET WITH:	Lydia Pabion - Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:20 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) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Lydia Pabion 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, a laundry room, front porch, and smoking area in the back. LPA conducted a tour of the facility with Jose de Leon and observed the following: Building is in good repair inside and outside. Lobby area was observed poster for Local Ombudsman and personal rights were observed in this area. Activity area is clean, fireplace is inaccessible to residents. Dining room was observed in good repair and clean. Kitchen was observed clean, storage of food supplies was observed with sufficient perishables for at least 2 days, and non-perishables for 7 days. A list of special diets was observed posted in the kitchen. LPA observed 6 random resident rooms and observed sufficient lighting, furniture, and bedding supplies. Each room has a bathroom and were observed in working condition. Water temperature was tested between 111.9 - 126.8 degrees F. which is not within the required 105-120 degrees F. Grab bars were not observed in room #121. Skid mats/strips were not observed in rooms #216 and 224. Ramps, and stairways were observed clear of obstructions. Both stairways were observed with an evacuation chair. Courtyard provides shaded sitting area, front porch provides sitting area, and back area provides a smoking area. Carbon monoxide/Smoke detectors were observed throughout and the facility has a fire sprinkler system. Fire extinguishers in hallways in each floor and last checked on 1/2/24. Last fire drill was conducted on 9/22/24. Additional linens, and cleaning supplies were observed in a closet. Sharps and chemicals were observed inaccessible to the residents. No large bodies of water were observed. LPA reviewed medication for 5 residents and files for 6 residents, of which one was under hospice and hospice plan was observed. Six staff files were reviewed. (CONTINUED ON LIC 809C)

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

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: 01/21/2025

NARRATIVE

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Each staff have 20 hours of training on file. Administrator certificate was observed for Lydia Pabion #6006152740 exp. date: 8/10/25.

Emergency disaster plan and infection control plan were reviewed and have been reviewed yearly. First Aid kit was observed.

LPA interviewed 4 residents and 4 staff.

Deficiencies have been noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/21/2025 02:05 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: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

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, the licensee did not comply with the section cited above in 2 out of 6 bathrooms were water temperature was observed and read as follow in room #110 temperature was measured at 122.0 degrees F., and in room #224 water temperature was testd at 126.8 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/22/2025
	Plan of Correction
1 2 3 4	Administrator will adjust water temperature to ensure temperature is between 105-120 degrees by POC due date 1/22/25. A daily water temperature log will be kept for 7 days and submitted to the department on 1/28/25.

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.

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 01/21/2025 02:05 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: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 6 rooms observed, room #216 and 224 did not have skid mat/strip which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/28/2025
	Plan of Correction
1 2 3 4	Administrator will replace skid mat or strips in room #216 and 224 showers and submit a copy to the department by POC due date 1/28/25.

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.

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC809 (FAS) - (06/04)

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