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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603952
Report Date: 06/16/2021
Date Signed: 06/16/2021 03:52:45 PM

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:
06/16/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:Lydia Pabion - Administrator TIME COMPLETED:
04:00 PM
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Licensing Program Analyst(s) Mary Flores conducted a Plan of Correction (POC) visit regarding deficiencies cited a case management visit conducted on 6/9/21.

87618(b)(3)(I) Oxygen administration - On 6/9/21 LPA observed two oxygen tanks in storage room #229. On today's visit LPA observed room #229 oxygen tanks have been removed. Administrator emailed LPA on 6/10/21 invoice of removal by Virgo Medical and Rehab Supply pick up on 6/9/21.

87468.1(a)(2) Personal Rights of Residents in all Facilities - On 6/9/21 LPA Flores observed 2 staff not wearing face mask properly per CDC guidelines. On today's visit LPA observed staff wearing face masks properly and administrator submitted in service training provided to staff on 6/10/21.

Deficiencies have been cleared. Exit interview with Lydia Pabion administrator and a copy of this report and
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
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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