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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602244
Report Date: 06/06/2023
Date Signed: 06/06/2023 04:14:33 PM

Document Has Been Signed on 06/06/2023 04:14 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: 92DATE:
06/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Ruby Garcia, AdministratorTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA arrived unannounced and met with staff Jennifer Tapia. Administrator, Ruby Garcia, arrived at 9:10am 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 are cleaning and disinfecting daily and more often for high touched surfaces. 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 14 rooms to inspect: #100, #103, #108, #119, #122, #126, #129, #202, #209, #220, #224, #226, #229, and #233. The rooms have the require 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 bathroom ceilings in disrepair between rooms #108 and #110. Operational Requirements: The facility is operating 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. 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 and some items have best by dates of 9/29/21, 4/28/22, and 7/30/22. Staffing: Per the administrator, there is sufficient staffing at the facility with 2 awake staff in the overnight shift. Staff have fingerprint clearance and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility and LPA selected 5 staff files for review. Administrator (Ruby Garcia) certificate expires on 2/27/24. Staff have current First Aid and/or CPR certificates. The required documentation such as medical assessment with TB results are included.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
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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Document Has Been Signed on 06/06/2023 04:14 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 06/06/2023 at 02:33 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: 06/06/2023

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 which the bathroom and bathroom hallway between rooms #108 and #110 have water stains and large cracks on the ceiling which poses a potential health and safety risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
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The licensee shall repair the bathroom ceiling between rooms #108 and #110 and send proof in which the damages have been repaired by POC due date 6/20/23.
Deficiency Dismissed
Type B
Section Cited
CCR
80076(a)(7)
80076 Food Services
(a) In facilities providing meals to clients, the following shall apply:
( 7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

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 which some of the emergency canned goods have passed the best by date which poses a potential health and safety risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
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The licensee shall ensure the canned goods have not expired and toss out the ones that have passed due dates. The licensee shall conduct an in-service training and remove all canned items that have expired by POC due date 6/20/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023


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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASADENA ADULT LIVING CENTER
FACILITY NUMBER: 198602244
VISIT DATE: 06/06/2023
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Client Rights - Information: Clients are provided with internet access devices. Client Records - Incident Reports: LPA reviewed 5 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 5 clients and they are being administered as prescribed by the physician. Incidental Medical & Dental: There are no clients who have 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 drills but not other types of drills. LPA provided a technical assistance to inform administrator to conduct quarterly emergency disaster drills on various shifts. Emergency Intervention: The staff do not need to use manual restraint on the clients at this facility.

The deficiencies were issued on the LIC809D. An exit interview was held. A copy of this report, LIC809D, LIC9102, and appeal rights were given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
LIC809 (FAS) - (06/04)
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