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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602244
Report Date: 11/20/2023
Date Signed: 11/20/2023 02:58:45 PM

Document Has Been Signed on 11/20/2023 02:58 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: 85DATE:
11/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Clarissa Basto - Medication SupervisorTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Zaragoza conducted a case management visit following the completion of a complaint visit which was conducted on 11/20/2023 and is related to the complaint investigation control #28-AS-20220121155956. LPA initially met with Clarissa Basto, Medication Supervisor for the facility, and explained the purpose of the visit. Administrator Ruby Garcia arrived shortly thereafter.

During the complaint visit, LPA toured room #128 of the facility along with its adjacent bathroom, and LPA observed that the condition of the room was poor. LPA observed that the ceiling fan located in the center of the room has an excessive amount of fan mold and dust on its blades and also surrounding the ceiling itself. Additionally, LPA observed that the windows of the bedroom were similarly covered in dust, and also found that the window in the bedroom cannot close and is therefore left slightly open and ajar. Furthermore LPA observed that the curtain covering the window in the shower room does contain tears in it as well. Pictures were taken of the state of the window, the ceiling fan, and the curtain that covers the bathroom's window curtain as well.

The deficiency is noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with caregiver and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
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 2
Document Has Been Signed on 11/20/2023 02:58 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 11/20/2023 at 02:17 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: PASADENA ADULT LIVING CENTER
FACILITY NUMBER: 198602244

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/18/2023
Section Cited
CCR
80072(a)(2)

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(a) Except for children's residential facilities, each client shall have personal rights which include, but are not limited to the following: (2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and/or equipment to mee his or her needs.
This regulation is not met as evidenced by:
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Administrator is to ensure that room #128 can provide a safe, healthful, and comofortable living environment to clients in care. Administrator is to repair, clean, or fix the room's window, the ceiling fan, and the bathroom's shower curtain by the POC due date.
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Based on observation, LPA found that the client bedroom #128 has a window that does not close, and is also covered in dust. Additionally the ceiling fan has an excessive amount of mold on it, and the curtain that covers the restroom's window has tears in it, which poses a potential health and safety risk.
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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:David Sicairos
LICENSING EVALUATOR NAME:Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023


LIC809 (FAS) - (06/04)
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