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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602244
Report Date: 05/08/2023
Date Signed: 05/08/2023 01:44:43 PM

Document Has Been Signed on 05/08/2023 01:44 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: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: 90DATE:
05/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Ruby GarciaTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit stemming from Death Report dated 04/20/23. LPA was met by Administrator Ruby Garcia and explained the purpose of the visit.

LPA requested and obtained a copy of Personnel Roster, Resident Roster, C1 face sheet, C1 Admissions agreement, and any other pertinent documents related to this visit. LPA is requesting Death Certificate for C1 when it becomes available.

LPA will review these documents and may return should further questions arise. No deficiencies or health and safety violations were observed at this time.

Exit interview was conducted and a copy of this report will be emailed to Administrator Ruby Garcia due to printer problems.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2023
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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