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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600449
Report Date: 10/21/2024
Date Signed: 10/21/2024 11:54:45 AM

Document Has Been Signed on 10/21/2024 11:54 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PRECISE CARE PASADENAFACILITY NUMBER:
198600449
ADMINISTRATOR/
DIRECTOR:		HEIM, CHARLOTTE D.FACILITY TYPE:
735
ADDRESS:1112 N. SIERRA BONITA AVENUETELEPHONE:
(626) 791-7701
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 1DATE:
10/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Charlotte Heim- AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) S Vaid conducted an unannounced annual visit at the facility using the Compliance and Regulatory Enforcement (CARE) inspection tool. LPA met with Charlotte Heim and explained the reason for the visit.

LPA conducted a tour of the facility with Charlotte Heim and observed the following:

Infection Control: Facility scans visitors. Office space stores PPE supplies and additional cleaning supplies. LPA reviewed infection control plan.

Physical Plant/ Environment: The facility is licensed to serve six (6) developmentally 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. Facility observed to be clean and in good repair, interior and exterior. Bedrooms three (3) are shared bedrooms and have sufficient lighting, furniture, and bedding supplies. Bathrooms two (2) were observed in working condition and water temperature was tested as follow in bathroom #1(inside room #1) 110.7 degrees F. and bathroom #2 water temperature tested at 115.7 which is within the required 105-120 degrees F. 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.

Operational Requirements: Program design reviewed. Fire clearance approved by LA FD for two (2) non-ambulatory clients.

Continued on 809C...................
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PRECISE CARE PASADENA
FACILITY NUMBER: 198600449
VISIT DATE: 10/21/2024
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Staffing: Ratio staff to client is 3:1.

Personnel Records/Staff Trainings: Renewal is pending, sent out July 30,2024. Administrator certificate for Charlotte Heim was observed #6019004735 exp. date: 7/30/24. Staff files were reviewed for criminal clearance, trainings, certifications, and health screenings. LPA reviewed 4 staff files.

Client Rights/Information: Access for internet and telephone during reasonable hours.

Food Service: 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. Emergency food supply observed in garage.

Client Records/Incident Reports: Clients files were reviewed to confirm emergency contact is updated and residents have health screenings and or vaccinations. LPA checked medication, and client's file. Per staff client handle their own P&I money.

Health Related Services: Clients are assisted with self-administration of prescription and non-prescription medications. Medication and sharps are kept in a cabinet with a lock and cleaning supplies are kept under the sink with a lock. Medications are administered as physicians’ orders.

Incident Medical and Dental: All clients have Needs and Services plan, Covid-19 vaccination cards on file.

Disaster Preparedness : Posted emergency disaster plan LIC 610 , containing emergency evacuation plans. Emergency drills- Earthquake and Fire, conducted on 10/02/24, quarterly.

Emergency Intervention: Manual restraint and or seclusion not practiced at this facility.


Exit interview was conducted with Charlotte Heim and a copy of this report, was provided
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC809 (FAS) - (06/04)
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