198601372-9-23-2025-28-AS-DKOI-DLSR3H-20250923123959

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601372
Report Date: 09/23/2025
Date Signed: 09/23/2025 12:40:52 PM

Document Has Been Signed on 09/23/2025 12:40 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ONE STEP AHEAD DAY PROGRAM		FACILITY NUMBER:	198601372
ADMINISTRATOR/ DIRECTOR:	HAMILTON, MARK		FACILITY TYPE:	775
ADDRESS:	421 DEL MONTE ST		TELEPHONE:	(626) 794-4103
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY: 60		CENSUS: 30	DATE:	09/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Phillip Jordan, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:45 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	Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced visit for an Annual Inspection. Upon arrival, LPA met with Phillip Jordan, the Administrator, who assisted with the visit. LPA explained the purpose for the visit. The facility is licensed to serve 60 Adults ages 18 and above. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies. Physical Plant & Environment Safety: This is a single- story facility located in Pasadena, CA. A tour of the facility includes: a bakery with walk-in freezer and walk-in oven, 3 storage closets, 4 client restrooms, 1 staff restroom, 2 staff office rooms, isolation room, activity room, craft room and outdoor shaded activity area. Smoke detectors and carbon monoxide detectors are operable and in compliance, there is an emergency sprinkler system throughout the facility that was last inspected on 05/15/2025. There are six (6) fire extinguishers that are fully charged and last inspected on 02/24/2025. No bodies of water were observed at the facility. The hot water temperature was tested throughout the facility restrooms and measured in bathroom #1 at 123.0, bathroom #2 at 124.5 degrees F, bathroom #3 at 125.0 degrees F, and bathroom #4 at 124.8 degrees F which are not within Title 22 Regulations of 105 degrees F to 120 degrees F.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ONE STEP AHEAD DAY PROGRAM	FACILITY NUMBER: 198601372
	VISIT DATE: 09/23/2025

NARRATIVE

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Physical Plant & Environment Safety: All storage areas for cleaning solutions, toxins, poisons and hazardous items are stored in a secured/locked storage closet and inaccessible to clients. There is a shaded rest area provided for the clients. Clients are provided with a non-contaminating water container that is readily available for indoor and outdoor use.

Operational Requirements: The facility has the appropriate fire clearance. Staff are knowledgeable on their reporting requirements.

Staffing: There appears to be sufficient staffing in the facility. There are at least ten (10) staff members on duty any time there are clients in the facility. The staff to client ratio is 1 caregiver to 3 consumers.

Personnel Records-Training: Staff files were available electronically during visit. LPA reviewed five (5) staff files that include Personnel Record, Health Screening, TB clearance, valid First Aid/CPR/AED training, and ongoing Staff training. The Administrator’s Certificate is valid and expires on 05/08/2027.

Client Records-Incident Reports: Client files are kept in a secure location within the staff office and LPA reviewed five (5) client files which includes the face sheet, Admission Agreement, Personal Rights, current Physician's Report, Ambulatory Status, TB clearance, and Annual Behavior Assessment Behavior Intervention Plan.

Client Rights-Information: Client Rights Poster is posted within the main office. Per Administrator, there are no clients that use postural supports.

Food Service: Pesticides and other similar toxic substances are not stored in food storage rooms or other kitchen areas.

Health Related Services: Per Administrator, the facility does not have any clients that take any medications. Rhe have at least one staff able to perform CPR.

Incidental Medical & Dental: Staff have proper training and training is documented within the personnel files. Per Administrator, there are no clients who have a restricted health condition.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ONE STEP AHEAD DAY PROGRAM	FACILITY NUMBER: 198601372
	VISIT DATE: 09/23/2025

NARRATIVE

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Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and relocation sites. Evacuation Procedures are in the facility’s Health and Safety file. The last Fire Drill was conducted on 09/18/2025. The last Earthquake/Disaster Drill was conducted on 05/01/2025.

Emergency Intervention: The Facility does not use any restraints or seclusion on clients. Clients at this facility do not require the use de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiency observed during today’s visit is documented on the 809-D. Exit interview was held and a copy of the report and appeal rights were provided to Phillip Jordan, Administrator.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/23/2025 12:40 PM - It Cannot Be Edited

Created By: Daniel Konishi On 09/23/2025 at 12:17 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: ONE STEP AHEAD DAY PROGRAM	FACILITY NUMBER: 198601372
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

82088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures 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
1 2 3 4	Based on observation, LPA tested the hot water temperature throughout the facility restrooms and LPA measured in bathroom #1 at 123.0, bathroom #2 at 124.5 degrees F, bathroom #3 at 125.0 degrees F, and bathroom #4 at 124.8 degrees F which are not within Title 22 Regulations of 105 degrees F to 120 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/24/2025
	Plan of Correction
1 2 3 4	Administrator shall immediately adjust water temperature. Administrator to check water temperature at various different times throughout the day and maintain and submit a water temperature log to the LPA for the next 3 days to ensure that hot water temperature falls within 105 degree F and 120 degrees F. Administrator will provide a copy of the log to the department once water temperature falls within Title 22 guidelines.

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.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

LIC809 (FAS) - (06/04)

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