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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605949
Report Date: 01/19/2023
Date Signed: 01/19/2023 01:44:51 PM

Document Has Been Signed on 01/19/2023 01:44 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:RETREAT, THEFACILITY NUMBER:
197605949
ADMINISTRATOR:AIMEE ARMENTAFACILITY TYPE:
740
ADDRESS:365 EL NIDO AVENUETELEPHONE:
(626) 356-2526
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 9CENSUS: 5DATE:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Claudia Romero - ManagerTIME COMPLETED:
02:00 PM
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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, an attached garage and backyard area.

LPA Flores conducted a tour of the facility with Claudia Romero Manager and observed the following:
Facility is clean and in good repair. Snacks were observed in kitchen's pantry and refrigerator. Cleaning supplies and sharps are kept in laundry room which is under lock. Medication is lock in kitchen's cabinet. Each resident bedroom was observed with sufficient lighting, the required furniture, and bedding supplies. Bedroom #3 has a covered fireplace. (4) resident bathrooms were observed, each with a skid mat, grab bars, and in working condition, water temperature was tested in each resident bathroom and tested between 107.2 - 113.7 which is within the required 105-120 degrees F. Living room area has a cover fireplace. Facility has a fire sprinkler system throughout the facility. Fire extinguisher is located across from kitchen entrance and in hallway outside bedroom #1 last checked on 2/28/22. Outdoor patio has a shaded sitting area. Facility is following infection control procedures. Signs were observed throughout the facility. Per administrator N95 mask fit testing has been schedule and will email the results of the staff that will provide direct care. LPA reviewed medication and files for 3 residents and files for 3 staff. A copy of liability insurance was requested.

No deficiencies were noted during this visit.

Exit interview was conducted with Claudia Romero Manager and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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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