<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600449
Report Date: 11/05/2022
Date Signed: 11/16/2022 09:25:48 AM

Document Has Been Signed on 11/16/2022 09:25 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PRECISE CARE PASADENAFACILITY NUMBER:
198600449
ADMINISTRATOR:HEIM, CHARLOTTE D.FACILITY TYPE:
735
ADDRESS:1112 N. SIERRA BONITA AVENUETELEPHONE:
(626) 791-7701
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 2DATE:
11/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:DSP, Jonathon LittletonTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/05/2022, Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA was allowed entry into this home by Jonathon Littleton (Direct Support Professional II (DSP II) and discussed the purpose of today's visit. Shortly after, LPA spoke with the Administrator, Charlotte Heim on the phone and explained the purpose of today's visit. Administrator stated she will not be able to come to the facility. The facility is vendorized by Frank D. Lanterman Regional Center and cares for Developmentally Disabled Adults ages 18 through 59 years. It is approved to serve six (6) clients, of which two (2) can be non ambulatory clients. Current census is two (2) ambulatory clients. LPA observed the facility plant, COVID-19 procedures, reviewed clients medications, observed food supplies and reviewed staff and resident files. This single-story home contains three (3) bedrooms, one of which is used as an office/storage room, two (2) full bathrooms, a living room, kitchen, dining area, backyard, and detached garage which is also used as activity/work out/TV-Computer room. LPA observed that the facility does not have a swimming pool or other bodies of water.

At 10:20am, LPA and DSP II Jonathon Littleton toured the facility and the following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet.
  • COVID-19 signs and posters were placed in several areas of the facility.
  • Facility maintained a 30-day supply of PPE located in the entrance area, the storage room and the detached garage.
  • Staff wore face mask throughout his shift.
****REPORT CONTINUED ON LIC 809-C*******
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2022
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: PRECISE CARE PASADENA
FACILITY NUMBER: 198600449
VISIT DATE: 11/05/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
  • The kitchen was inspected. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All the appliances are clean and are working properly.
  • Knives and sharps were locked along with the medication in the kitchen cabinet and inaccessible to clients.
  • Cleaning solutions were also locked and inaccessible to clients.
  • The laundry room which is located outside is clean and has cleaning supplies inaccessible to residents. Washing machine and dryer are working properly.
  • At 10:30am, water temperature was measured in the kitchen and bathrooms. Kitchen water temperature read at 121.3 deg. F, bathroom #1 water temperature read 123.2 deg. F and bathroom #2 water temperature read at 121.4 deg. F. DSP II Jonathon Littleton immediately adjusted water meter and all areas measured within 105-120 F. The hot water was 105.1 deg. F in the kitchen, 106.2 deg F in bathroom #1 and 106.5 deg. F in bathroom #2. Hot water temperature is within Title 22 regulations.
  • Two (2) client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space.
  • Both bathrooms contained hygiene supplies including liquid soap, paper towels, and toilet paper.
  • Medications were locked, centrally stored, and given as prescribed. Medications were reviewed for all clients and facility maintained a 30-day supply of medications.
  • The common areas such as the living room, dining room are clean and have the required furniture.
  • The backyard has a sitting area and has been designated as the visitor area during the COVID-19 pandemic.
  • There are two (2) fire extinguishers, one (1) in the hallway and one (1) in the kitchen. One of the fire extinguishers located in the hallway is not fully charged and not up-to-date.
  • LPA observed cameras in the common areas and Administrator confirmed there is no audio. There were no cameras seen in private areas.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • Clients files were reviewed to confirm emergency contact is updated and residents have health screenings and or vaccinations Client files were inspected, and emergency contact information was up to date.
  • Administrator certificate expires 7/30/2022.

Deficiencies were cited, exit interview conducted, and copy of the report and appeals rights were provided to DSP II, Jonathon Littleton.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/16/2022 09:25 AM - It Cannot Be Edited


Created By: Bennette Pena On 11/05/2022 at 12:24 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: PRECISE CARE PASADENA
FACILITY NUMBER: 198600449

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, the licensee did not comply with the section cited above in which during LPAs tour of facility, LPA observed that although one of the fire extinguishers located in the kitchen is operational, the other one that is mounted in the hallway next to the bathroom is not properly charged. This poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 11/06/2022
Plan of Correction
1
2
3
4
The Administrator will ensure that fire extinguishers in the facility are in operational condition at all times. Submit evidence of new and updated fire extinguisher, photos and copy of the receipt to show purchase date to LPA on or before POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/16/2022 09:25 AM - It Cannot Be Edited


Created By: Bennette Pena On 11/05/2022 at 12:31 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: PRECISE CARE PASADENA
FACILITY NUMBER: 198600449

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064.3(d)
85064.3
Administrator Recertification Requirements. (d) To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department's Administrator Certification Section, post-marked on, or up to ninety (90) days before, the certificate expiration date:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in that the Administrator Certificate expired 7/30/2022, which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 11/18/2022
Plan of Correction
1
2
3
4
Administrator agreed to submit a copy of the current Administrator license by email or phone to LPA on or before the POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4