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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602265
Report Date: 03/11/2022
Date Signed: 03/11/2022 01:10:58 PM

Document Has Been Signed on 03/11/2022 01:10 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SHADY ACRES GUEST HOMEFACILITY NUMBER:
198602265
ADMINISTRATOR:WILLIAMS, CHRISTINEFACILITY TYPE:
735
ADDRESS:901 N LOS ROBLES AVETELEPHONE:
(626) 356-9168
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 10CENSUS: 8DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Administrator Asenaca ReniteTIME COMPLETED:
01:13 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1-year visit focusing on COVID-19 Infection Control Practices. LPA was greeted by Dioselina Espinel DSP and Spoke with Licensee Christine Williams via phone. Administrator Asenaca Ranitu arrived a short time later. LPA explained the purpose of the visit. Administrator certificate expires 09/22/22 Last fire drill was on 12/20/2021. Licensee stated she will pay fees today. Keep same address.
Structure:
The Facility is a single storey building in a residential area with 5 shared client bedrooms and there’s 1 dining rooms, 2 full bathrooms, a kitchen. A laundry room, a family room. There is a garden area on the back premises with tables and chairs and shade. All the resident’s bedrooms are spacious and will easily accommodate the resident's furnishings. The passageway and walkways are free of hazard and free from obstruction.
The following were observed/inspected:
· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Water temperature measured between 105 – 120 degrees F which is within regulation range.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility does have one designated isolation room.
· Three client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Three client rooms were equipped with alcohol-based hand sanitizer.
· Eight (8) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable food for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed posted at facility.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· Deficiencies were observed during today’s visit. (please see 809D)
· Exit interview was conducted with Administrator Asenaca Ranitu. A copy of the report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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 03/11/2022 01:10 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/11/2022 at 12:52 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: SHADY ACRES GUEST HOME
FACILITY NUMBER: 198602265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 which poses/posed a potential health, safety or personal rights risk to persons in care. LPA Observed window screen in bathroom next to room #3 in disreapir
POC Due Date: 03/18/2022
Plan of Correction
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Administrator will repair screen by POC date and send photo as proof of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Christine Yee
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022


LIC809 (FAS) - (06/04)
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