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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600449
Report Date: 10/23/2023
Date Signed: 10/23/2023 10:49:54 AM

Document Has Been Signed on 10/23/2023 10:49 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: 1DATE:
10/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Christopher Heim - Direct Support StaffTIME COMPLETED:
11:00 AM
NARRATIVE
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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 Christopher Heim and explained the reason for the visit.
The facility is licensed to serve six (6) Developmental Disabled adults ages 18 thru 59 years, of which two (2) can be non-ambulatory clients. Facility is a single-story home in a residential neighborhood and consist of three (3) bedrooms, office/storage room, two (2) full bathrooms, a living room, kitchen, dining area, backyard, a laundry room, and detached garage.

LPA Flores conducted a tour of the facility with Christopher Heim and observed the following:
Facility is in cleaned and in good repair inside and outdoor. Kitchen was observed and has stored sufficient food for (1) one client for at least two days of perishables and 7 days of non-perishables. Refrigerator/ Freezer was observed no thermometers available. Medication and sharps are kept in a cabinet with a lock and cleaning supplies are kept under the sink with a lock. Bedrooms (3) are shared bedrooms and have sufficient lighting, furniture, and bedding supplies. Bathrooms (2) were observed in working condition and water temperature was tested as follow in bathroom #1(inside room #1) (B1) water temperature tested at 127.0 degrees F. and bathroom #2(B2) water temperature tested at 128.9 which is not within the required 105-120 degrees F. Office space stores PPE supplies and additional cleaning supplies. The front porch serves as the shaded seating area. Backyard has seating space. Smoke/Carbon Monoxide detectors were tested and in working condition. No large bodies of water were observed. Fire extinguisher was observed. Last Fire drill was conducted on 10/1/23.
LPA checked medication, and client's file. Per staff client gets their own P&I money. LPA reviewed 4 staff files. LPA reviewed infection control plan and emergency disaster plan (version 10/03). Administrator certificate for Charlotte Heim was observed #6019004735 exp. date: 7/30/24.
Deficiencies are noted on LIC 809D per Title 22 Regulations.
Exit interview was conducted with Christopher Heim and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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
Document Has Been Signed on 10/23/2023 10:49 AM - It Cannot Be Edited


Created By: Mary G Flores On 10/23/2023 at 10:21 AM
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: 10/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in water temperature tested at 127 degrees F., in B1 and 128.9 degrees F., in B2 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Administrator will adjust water heater temperature and will certify in writing that will ensure water temperature is kept at the require temperature of 105-120 degrees F., at all times by POC due date 10/24/23. Administrator will keep a water temperature log for 10/24/23 - 10/31/23 and will submit the log by 10/31/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/23/2023 10:49 AM - It Cannot Be Edited


Created By: Mary G Flores On 10/23/2023 at 10:21 AM
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: 10/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(2)
Food Service
(2) Freezers shall be large enough to accommodate required perishables and shall be maintained at a temperature of zero degrees F (-17.7 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in freezer did not have a thermometer to review temperature which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2023
Plan of Correction
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Administrator will provide a thermometer in the freezer and ensure is within the correct temperature and will submit a picture by POC due date 10/30/23.
Type B
Section Cited
CCR
85076(d)(3)
Food Service
(3) Refrigerators shall be large enough to accommodate required perishables and shall maintain a maximum temperature of 45 degrees F (7.2 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in refrigerator did not have a thermometer to review temperature which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2023
Plan of Correction
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Administrator will provide a thermometer in the refrigerator and ensure is within the correct temperature and will submit a picture by POC due date 10/30/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/23/2023 10:49 AM - It Cannot Be Edited


Created By: Mary G Flores On 10/23/2023 at 10:21 AM
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: 10/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in LIC 610 version 10/03 was reviewed during this visit, per updates facilities should have udpated to LIC 610 versioin 12/21 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2023
Plan of Correction
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Administrator will update LIC 610 to current version (12/21) and submit a copy to the department by POC due date 10/30/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023


LIC809 (FAS) - (06/04)
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