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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605949
Report Date: 02/09/2022
Date Signed: 02/09/2022 11:22:33 AM

Document Has Been Signed on 02/09/2022 11:22 AM - 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:
02/09/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Claudia Romero - ManagerTIME COMPLETED:
11:35 AM
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control domain, medication, and food review. LPA Flores met with Claudia Romero facility's manager and explained the reason for the visit.

The facility is licensed to serve 9 non-ambulatory residents and has an approved Hospice Waiver for 2 residents. There is also a Dementia Program in place and a Food Service waiver to prepare food off premises and transport to the facility. The facility is a one single home with a kitchen, 5 private bedrooms 4 bathrooms; separate detached laundry area, garage and backyard area. Facility has a fire sprinkler system throughout the facility, smoke/carbon monoxide detector in the dinning room that was tested and working. Fire extinguisher is located across from kitchen entrance.

LPA Flores conducted a tour of the facility with and observed the following:
Kitchen area: medication cabinet kept locked no sharps observed.. Chemical solutions locked in laundry area. Facility maintains snacks available in pantry and refrigerator. All (5) bedrooms have sufficient lighting, all required furniture and bedding. All resident's bathrooms have the required grab bars, mats, and water temperature was tested in bathroom #1 water temperature tested at 109.4 degrees F, bathroom #2 water temperature tested at 105.6 degrees F., bathroom #3 water temperature tested at 105.3 degrees F., and bathroom #4 water temperature tested at 105.2. Facility living room has a fireplace that is covered. Administrator certificate was observed for Claudia Romero #6002551740 expiration date 10/17/23.Facility is following COVID 19 recommendations by screening visitors, staff, and residents. Signs were observed. Hand washing signs posted near sinks, hand soap, and paper towels available. Staff have not been fit tested for N95s. PPE supplies were observed sufficient for 30 days.

No deficiencies were given during this visit. Technical advisory was provided.
Exit interview was conducted with Claudia Romero Manager and a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
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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