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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601166
Report Date: 04/15/2022
Date Signed: 04/15/2022 01:50:06 PM

Document Has Been Signed on 04/15/2022 01:50 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GLEN MEADOWS ANNEXFACILITY NUMBER:
198601166
ADMINISTRATOR:ALYCE EASTONFACILITY TYPE:
735
ADDRESS:1385 NORTH MENTOR AVETELEPHONE:
(626) 791-1690
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
04/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Monique Jordan AdministratorTIME COMPLETED:
01:57 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez and Bennette Pena conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPAs met with Administrator Monique Jordan and explained the purpose of the visit. Home is Level 4 Home. The home has 6 ambulatory clients, none have a restricted health care condition and all clients are between the ages of 18-59. Facility is a two story home located in a residential area consisting of 2 private rooms and 2 shared rooms,2 bathrooms, living room, dining room, backyard patio area, and detached garage. The last fire drill was completed on November 18, 2021. Administrator certificate expires 4/06/2023

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Facility has one designated isolation room.
· 2 share and 2 private rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· All client rooms were not equipped with alcohol-based hand sanitizer but available throughout the facility
· Six (6) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2022
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
Document Has Been Signed on 04/15/2022 01:50 PM - It Cannot Be Edited


Created By: Alberto Lopez On 04/15/2022 at 01:08 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: GLEN MEADOWS ANNEX
FACILITY NUMBER: 198601166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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. LPAs oberved cleaning solution accesible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
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Administrator will lock up cleaning solutions and have them inaccesible to cleints. ADMISTRATOR CORRECTED AT TIME OF VISIT AND LOCKED CLEANIG SOLUTION.
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, LPAs and Administrator observered the water temperture at 132.9 degrees F which is not within regulation and poses and health and safety issue to clients in care.
POC Due Date: 04/18/2022
Plan of Correction
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Administrator will adjust water temperture and measure it for 3 days and send video or picture and self certify that it has been corrected.
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:Christine Yee
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/15/2022 01:50 PM - It Cannot Be Edited


Created By: Alberto Lopez On 04/15/2022 at 01:08 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: GLEN MEADOWS ANNEX
FACILITY NUMBER: 198601166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the facility did not meet this requirement as LPAs and Adminitrator oberseved , one borken facet in downstairs bathroom sink, One broken window frame at in room 4, back patio corner edge broken and has nails protuding from the side, and the home has several areas on the outside structure that has paint peeling which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
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Administrator will fix facet, broken window frame, back patio corner edge, and address the peeling paint around the home by POC date and send photos as proof.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPAs and Administrator observed torn screens that need replacement which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
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Administrator will replace screens by POC date and send pictures to LPA by POC date as proof of correction.
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:Christine Yee
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GLEN MEADOWS ANNEX
FACILITY NUMBER: 198601166
VISIT DATE: 04/15/2022
NARRATIVE
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· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· Deficiencies cited (see 809D for details).

Exit interview was conducted with Assistant Administrator Monique Jordan . A copy of the report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4