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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605949
Report Date: 08/25/2021
Date Signed: 08/30/2021 11:11:18 PM

Document Has Been Signed on 08/30/2021 11:11 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:RETREAT, THEFACILITY NUMBER:
197605949
ADMINISTRATOR:AIMEE ARMENTAFACILITY TYPE:
740
ADDRESS:365 EL NIDO AVENUETELEPHONE:
(626) 356-2526
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 9CENSUS: 4DATE:
08/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Claudia Romero, SupervisorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Linda Almaraz conducted an annual required visit at the above facility. LPA met with Supervisor Claudia Romero and Administrator Aimee Armenta later arrived during the inspection. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, food supply and Personal Protective Equipment (PPE). Facility has submitted a mitigation plan and is approved.

LPA inspected all (5) bedrooms, (4) residents bathrooms, dining and living room. Facility has a main entry point for screening. Each bedroom has a chair, bed, linen, dresser, light, sufficient closet space and required furniture and equipment. All bathrooms were toured and the toilets, hand washing and showers are safe and sanitary. The common areas such as living room and dining area are clean and have the required furniture. Medications are centrally stored, locked along with the records. Resident Medication logs and medication were reviewed along with emergency contact information. Staff training records for COVID-19 were reviewed. Smoke alarm and Carbon monoxide detectors were inspected and seem to be operational. The facility has (3) fire extinguisher that are within the required operable range.

The hot water temperature in bathroom #1 measured at 136.6 degrees F.

Deficiencies cited under California Code of Regulations Title 22

An exit interview was conducted with the Administrator and a hardcopy was provided. Appeal Rights was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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 2
Document Has Been Signed on 08/30/2021 11:11 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 08/25/2021 at 12:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RETREAT, THE
FACILITY NUMBER: 197605949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)


This requirement is not met as evidenced by:LPA and staff Claudia Romero checked water temperature for bathroom #1 which was at 136.6 degrees F.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2021
Plan of Correction
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The administrator shall adjust water temperature for the whole facility to be within limits of 105-120 degrees F and will monitoring/log the readings for 7 days. Licensee will send monitoring log as proof of correction to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Christine Yee
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2021


LIC809 (FAS) - (06/04)
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