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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605949
Report Date: 01/18/2024
Date Signed: 01/18/2024 01:04:20 PM


Document Has Been Signed on 01/18/2024 01:04 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:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Adriana Garcia - CaregiverTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Adriana Garcia and explained the reason of the visit.

The facility is licensed to serve 9 non-ambulatory residents ages 60 and over, and has an approved Hospice Waiver for no more than 5 residents. Facility has a Dementia Program in place and a Food Service Waiver to prepare food off premises and transport to the facility. The facility is a single home in a residential area, with a kitchen, living room, dining room, entry area, sun room area, 5 bedrooms 4 bathrooms, visitor's/staff bathroom, laundry area, an detached garage, front court, and a backyard area.

LPA Flores conducted a tour of the facility with Adriana Garcia and observed the following:
Facility's indoor and outdoor is in good repair. Living room, dining room, sun room area have sufficient sitting area, are clean, and in good repair. Kitchen is clean, snacks were observed, and daily food is refrigerated. Medication cabinet was observed locked. Laundry room is inaccessible to the residents and cleaning supplies, knives are stored here. Resident's rooms (5) have the required furniture, bedding supplies and sufficient lighting. Bathrooms (4) in resident's rooms are in working condition, have grab bars, and skid mats. Water temperature was tested in each, between 105.2 - 112.6 degrees F. Fireplace located in living room and in 2 resident's rooms are covered. Emergency food supplies, water, and a generator were observed in the garage. Facility has a fire sprinkle system throughout. Fire extinguishers were observed throughout the home and last checked on 2/2/7/23. Carbon Monoxide detectors were observed. Fire Department Inspection report was last conducted on 4/6/23. Backyard and passageways were observed clean, and free of obstruction/debris. A copy of Liability Insurance was obtained.
LPA reviewed Infection Control plan, and Emergency Disaster Plan both reviewed yearly by facility staff. LPA reviewed medication and files for 5 residents and 5 staff files. Staff #5(S5) was hired on 12/30/23 and health screening is pending.
No Deficiencies were noted today.
Exit interview was conducted with Claudia Romero Manager and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
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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