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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602244
Report Date: 07/07/2026
Date Signed: 07/07/2026 03:56:34 PM

Document Has Been Signed on 07/07/2026 03:56 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: 80DATE:
07/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:59 AM
MET WITH:Ruby Garcia, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA met with Ruby Garcia, Administrator, and the reason for the visit was explained. The facility is licensed to serve 136 clients aged 18-59; ambulatory only with an approved Hospice waiver for (5) clients. The facility is operating within the scope of its license. There are currently 80 clients living in the facility.

The facility is in a residential area of Pasadena. The building consists of 2 floors and a basement. The 1st floor has 29 client rooms, dining room, kitchen, laundry room, food storage room, housekeeping supply room, medication room, main office and bookkeeping office. The 2nd floor has 41 client rooms, employee lounge, activity room, TV room, and activity closet.

The facility is currently undergoing physical plant renovations. Administrator provided the department with Phase 1 and Phase 2 renovations plans. During today’s visit, the following was observed:

The facility was observed clean inside and out. Passageways, hallways, stairwells, ramps and exits are free of debris and obstruction. Proper hallway lighting is available. Ten random client bedrooms on the first and second floor were inspected and observed to have required furniture, bedding and sufficient lighting. Bathrooms were also observed clean and showers have safety grab bars. Water temperature was tested in client bathrooms and measured within compliance range of 105-120 degrees F. Client bedrooms have sufficient closet space, and bedrooms were observed to maintain a temperature between 78.3 – 81.3 degrees F. The common areas in the facility are also kept clean.

**Continues on LIC 809-C**

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/07/2026
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The kitchen was observed clean and sanitary for the storage and preparation of meals. Refrigerators and freezers have thermometers and maintain proper temperatures. Food pantry is clean and food is stored properly. Food is kept within "best when used by" and expiration dates limits. Sufficient 2-day perishable and 7-day non-perishable food supply was observed. Dishwashing area and equipment are kept clean and operational. Laundry room appliances are operational and detergents are kept locked. LPA observed sufficient cleaning supplies and extra bedding and towels. There are no pools or large bodies of water. Shaded area in the back has sufficient seating available. Garden is maintained and walking paths are clear and free of obstructions.

LPA inspected the medication room. Medication is kept centrally stored and inaccessible to clients. Review of medication for (6) clients was conducted. Medication was observed to be administered and documented per physician orders.

Carbon monoxide detectors throughout the first and second floor were observed and tested during visit and were found to be working properly. The facility is equipped with hardwired smoke detectors which were last inspected and tested on 6/19/2026 by a fire monitoring company, according to records maintained at the facility. The facility is also equipped with fire extinguishers on all floors and were observed charged and last inspected on 6/19/2026. Fire drills are conducted every other month. Last drill was conducted on 3/5/2026.

LPA conducted review of (8) client and (6) staff files. Client files contain required documents like medical assessments, admission agreements and Appraisals/Needs and Service Plans. Staff files contain the proper criminal background clearances, health screenings and training documents.

No deficiencies noted. Exit interview was conducted with Ruby Garcia, Administrator, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC809 (FAS) - (06/04)
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