198601166-4-29-2023-28-AS-KRAZ-CRCVJ3-20230429162803

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601166
Report Date: 04/29/2023
Date Signed: 04/29/2023 04:29:05 PM

Document Has Been Signed on 04/29/2023 04:29 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:	GLEN MEADOWS ANNEX		FACILITY NUMBER:	198601166
ADMINISTRATOR:	ALYCE EASTON		FACILITY TYPE:	735
ADDRESS:	1385 NORTH MENTOR AVE		TELEPHONE:	(626) 791-1690
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY: 6		CENSUS: 6	DATE:	04/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Monique Jordan		TIME COMPLETED:	01:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 04/29/2023 at 9:02 am. LPA was met by Staff 1 (S1) and explained the purpose of the visit. Administrator Monique Jordan later arrived to the facility and assisted with tour. Facility is licensed to serve clients 18 to 59 years old. The facility has a fire clearance approved for six (6) ambulatory. There are six (4) level 4H developmentally disabled clients residing at this facility. Clients at this facility are receiving services from Frank D Lanterman Regional Center. LPA requested and obtained a copy of Personnel Report, and Resident Roster.

LPA OBSERVATIONS: Tour began at 9:07 am and was led Administrator Jordan. The Facility is a two-story building located in a residential area with four (4) client bedrooms, one (1) client shared bathroom, one (1) staff bathroom, kitchen, dining room, front yard, backyard and detached garage.

· Front Yard: Was clean and well maintained. No hazards were observed.

· Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. At 9:17 am, LPA observed knives and sharps located in nearby cabinet to be inaccessible to 6 out of 6 clients in care. At 9:19 am, LPA observed several bottles of cleaning solutions and disinfectants under kitchen sink cabinet to be inaccessible to 6 out of 6 clients in care. Kitchen water temperature read 110.3 degrees F.

· Dining Room/Living room: Dining room was observed to be clean and contained one table and 6 chairs. Living room was observed to contain 6 sofa chairs and contain plenty of lighting. LPA observed 6 out of 6 clients watching TV and relaxing in living room area during visit.

· Linen Closet: Contained plenty linens, towels, and hygiene products.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2023

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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Document Has Been Signed on 04/29/2023 04:29 PM - It Cannot Be Edited

Created By: Kimberly Ramirez On 04/29/2023 at 10:48 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: GLEN MEADOWS ANNEX	FACILITY NUMBER: 198601166
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2023

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
1 2 3 4	Based on observation, kitchhen cabinet knob was observed to be missing, client bedroom 4 closet knob is broken, light in client bedroom 4 closet/platroom needs to be replaced, the licensee did not comply with the section cited above in 6 out of 6 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2023
	Plan of Correction
1 2 3 4	Licensee will replace knobs in kitchen cabinet, bedroom 4 closet door and replace light bulb in client bedroom closet/playroom. Licensee will send photo proof of corrections via email to LPA.

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
1 2 3 4	Based on observation,window screen in shared client bathroom were dirty with debris and client bedroom 4 screen was torn and dirty with debris, the licensee did not comply with the section cited above in 6 out of 6 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2023
	Plan of Correction
1 2 3 4	Licensee will clean screens and send photo proof to LPA via email of clean screen. Licensee will replace screen in client bedroom 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:

Tony Vasallo

LICENSING EVALUATOR NAME:

Kimberly Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GLEN MEADOWS ANNEX	FACILITY NUMBER: 198601166
	VISIT DATE: 04/29/2023

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· Client Rooms 1 - 4: All contained the required furnishings, linens and were observed to be clean with plenty of closet space. Client bedrooms 3 and 4 are located upstairs.

· Bathrooms: Shared client bathroom# 1 was observed to be clean and contained soap and paper towels. Signs promoting hand washing were observed. Water temperature in this bathroom was measured at 111.5 degrees F which is in the required 105 – 120 degrees F. Staff bathroom is locked and inaccessible to clients.

· Centrally Stored Medications: LPA’s observed cabinet located near kitchen to be locked and inaccessible to residents. LPA reviewed 6 client medications and Medication Administration Record (MAR).

· Backyard: Clean and free from hazards. LPA observed plenty of seating and shade. No large bodies of water ere observed.

LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit. Administrator certificate was observed for Monique Jordan with an expiration date of 04/06/23 however, per Administrator Jordan, she renewed it and is awaiting processing. Last fire drill was conducted on 02/24/23 and last earthquake drill was conducted on 02/11/23. First Aid kit was inspected. 6 out of 6 clients records were reviewed. 5 staff files were reviewed.

Deficiencies are being cited during visit. Exit interview was conducted with Staff S1 and a copy of this report, LIC 809-D, and appeals rights was provided via email due to printer problems.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2023

LIC809 (FAS) - (06/04)

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