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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602244
Report Date: 09/22/2022
Date Signed: 09/22/2022 03:24:01 PM

Document Has Been Signed on 09/22/2022 03:24 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:PASADENA ADULT LIVING CENTERFACILITY NUMBER:
198602244
ADMINISTRATOR:GARCIA, RUBYFACILITY TYPE:
735
ADDRESS:1415 N GARFIELD AVETELEPHONE:
(626) 398-9647
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 136CENSUS: 94DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:08 PM
MET WITH:Ruby Garcia - AdministratorTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, medication, and food review. LPA met with Ruby Garcia Administrator and explained the reason for the visit.

The facility is licensed to serve 136 ambulatory clients ages 18-59 years old with an approved hospice waiver for 5 residents. Facility is a two story building located in a residential area, with a commercial kitchen, a patio, a medication/office room in the first floor, an activity and TV room in the second floor.
LPA conducted a tour of the facility with Ruby Garcia - Administrator and observed the following:
LPA Flores observed 10 randomly chosen client rooms #105,109,123,126,132,201,205,209,220,225. Each room has sufficient furniture, bedding, and lighting, room's bathrooms were observed in working condition and water temperature was tested between 98.3 to 119.8 degrees F. which is not within the required 105-120 degrees F. Bathroom in room #105 had a broken window on the lower left side of about 3 inches in length and 2 inches in width, An unattended housekeeper cart with accessible cleaning supplies was observed in room #109 and the bathroom had a hole in the ceiling over the shower of about 12 inches by 6 inches. Facility has a fire sprinkler system throughout. Fire extinguishers were observed throughout the facility and kitchen and last checked on July 2022. Commercial kitchen was observed operable and sufficient food for at least 2 days of perishables and 7 days of non-perishable supplies were observed. No large bodies of water were observed. Medication was observed to be centrally stored in medication room and medication for 10 clients were reviewed.
LPA observed signs throughout the facility for hand-washing, cough/sneeze etiquette, and symptoms. Screening and visitor log was conducted. Infection control is observed by staff regarding cleaning, testing, and practices. PPE supplies were observed for at least 30 days. Staff have not been fit test for N95.

Deficiencies were noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Ruby Garcia - Administrator and a copy of this report, LIC 809D, technical advisory and appeal rights was provided,
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
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 09/22/2022 03:24 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/22/2022 at 02:31 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: PASADENA ADULT LIVING CENTER
FACILITY NUMBER: 198602244

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

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 in cleaning supplies in housekeeper's cart were unattended and accessible to clients in room #109 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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Administrator will ensure cleaning supplies are unaccessible to clients at all times, certify in LIC 9098 and submit to the department by 9/23/22. Administrator will provide training to staff on section 80087 and submit sign-in log and agenda to the department by 9/29/22.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 09/22/2022 03:24 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/22/2022 at 02:31 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: PASADENA ADULT LIVING CENTER
FACILITY NUMBER: 198602244

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

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 licensee did not comply with the section cited above in window in bathroom's room #105 was broken and a hole in ceiling over shower was observed in bathroom's room #109 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2022
Plan of Correction
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Administrator will repair bathroom's window in room #105 and ceiling hole in room #109, and will submit pictures of repairs to the department by POC due date 10/6/22.
Type B
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 in bathroom's room #132 tested at 98.3, #225 tested at 103.5 degrees F., which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2022
Plan of Correction
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Administrator will ensure water temperature is maintained at the required 105-120 degrees F., at all times, will maintain a log for room #132 and #225 for 7 days and submit to the department by 10/6/22.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
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