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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602244
Report Date: 07/23/2024
Date Signed: 08/28/2024 04:06:58 PM

Document Has Been Signed on 08/28/2024 04:06 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:PASADENA ADULT LIVING CENTERFACILITY NUMBER:
198602244
ADMINISTRATOR/
DIRECTOR:		GARCIA, RUBYFACILITY TYPE:
735
ADDRESS:1415 N GARFIELD AVETELEPHONE:
(626) 398-9647
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 136CENSUS: 83DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Ruby Garcia, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) S Vaid conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA arrived unannounced at 08:50 AM and met with staff Jennifer Tapia. Administrator, Ruby Garcia, arrived at 9:40am to assist with the visit. The license is approved to serve 136 ambulatory clients, ages 18 - 59 and has an approved hospice waiver for 5 clients.

The following domains were reviewed/inspected during today's visit:
Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff clean and disinfect daily and more often for high touch surfaces. The facility has sufficient PPE supplies. Physical Plant & Environment Safety: The facility has 2 floors with client bedrooms and a basement that consists of corporate offices. LPA randomly selected 10 rooms to inspect: #132, #133, #123, #117, #109, #210, #203, #217, #229, #235. The rooms have the required furniture and are free of insects. The spacious backyard has tables and chairs for client use. There are no pools or bodies of water on the premises. The hot water temperature is measured within the required range of 105-120 degrees F. During the walk through, LPA observed the facility clean, good smell, and debris free. Operational Requirements: The facility operates within the approved fire clearance. Per administrator, all the clients are ambulatory and can independently manage their own ADLs. Food Service: There are sufficient food supplies of 2-day perishable and at least a week of non-perishable items. The freezer is maintained at a temperature of 0-degree F and the refrigerator at a maximum of 45 degrees F. LPA inspected the emergency supplies of canned goods, all cans checked are within expiration dates. Staffing: Per the administrator, there is sufficient staffing at the facility with 2 awake staff in the overnight shift. Staff have fingerprint clearance and are associated with the facility. Personnel Records-Training: Staff files are maintained at the facility and LPA selected 6 staff files for review. Administrator (Ruby Garcia) certificate expires on 02/27/24, sent for renewal on 01/22/24 . Staff have current First Aid and/or CPR certificates. The required documentation such as medical assessment with TB results is included.
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SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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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: PASADENA ADULT LIVING CENTER
FACILITY NUMBER: 198602244
VISIT DATE: 07/23/2024
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Client Rights - Information: Clients are provided with internet access devices. Client Records - Incident Reports: LPA reviewed 6 Client files. The files include the admission agreement, medical assessment with TB results, consent forms, and Appraisal/Needs and Services Plan. There is one client who self-administers the insulin injection medication. Health-Related Services: The medications are centrally stored in the main office. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility keeps a separate PRN medication book and logs down medication when given. LPA reviewed medications for 6 clients, and they are being administered as prescribed by the physician. Incidental Medical & Dental: There are no clients with prohibited health conditions. There is one who receives insulin injection in which client self-administers and some that use an inhaler. Disaster Preparedness: The facility has an updated Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The plan includes utility shutoff valves and procedures during evacuations. Facility is conducting quarterly fire/earthquake drills last drill was conducted 05/17/24, during various shifts. Emergency Intervention: The staff do not need to use manual restraint on the clients at this facility.

There are no deficiencies observed at this visit. An exit interview was held. A copy of this report, was given to the administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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