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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602265
Report Date: 11/08/2022
Date Signed: 10/10/2023 08:04:57 AM

Document Has Been Signed on 10/10/2023 08:04 AM - 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: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: 7DATE:
11/08/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Asenaca RanituTIME COMPLETED:
10:16 AM
NARRATIVE
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An informal meeting was held virtually via Microsoft Teams on 11/08/2022 @ 10:00am PST. The attendees present during the meeting were: Licensing Program Analyst (LPA) Bennette Pena, Licensing Program Manager (LPM) David Sicairos, Regional Manager (RM) Araceli Ramirez, Pasadena Public Health Dept. (PPHD) Community Services Representative III Misael Rivera, PPHD Public Nurse Casey Cortes, PPHD Community Service Representative Adrian Griffin, PPHD Medical Asst. Quitzia Gonzalez and Administrator, Asenaca Ranitu. The facility's licensee, Christine Williams was not able to join. RM A. Ramirez pointed out the importance of having the Licensee in the meeting as they are ultimately responsible to the day to day function of the facility. The purpose of this informal meeting was to discuss the facility's compliance with PPHD. CCLD's goal is to ensure that all 3 entities (CCLD, PPHD and Facility) understand and agree with Covid reporting requirements and guidelines.
DISCUSSION:
  • Facility's Administrator reached out to PPHD over the weekend to find out what information is missing and to get clarification on the reports. PHN Casey Cortes is in communication with the Administrator and PPHD is thankful for the facility's initiative.
  • PPHD is reviewing all the information/reports sent by the facility and will advise their clearance status. Until clearance status is sent out, facility is still responsible in submitting reports.
  • PPHD need to receive covid + cases and all reports in a timely manner, at least 24hrs after a covid + detection. This will allow PPHD to give the best guidance to facility and can quickly move/re-group facility back to surveillance testing.
  • PPHD addressed the several types of status for facilities:
SURVEILLANCE - no active covid + at the moment. No testing required, only WEEKLY reports (submit on Mondays).
RESPONSE – needs 3 rounds of testing and daily reporting. Shady Acres is currently under this status.
OUTBREAK – facility was under this back in May but due to no communication with the facility, PPHD was not able to get information.
  • PPHD pointed out that if there is an epilink in the facility, even a single case, it is considered an outbreak.
  • PPHD reiterated that its purpose is to have constant communication with the facilities and their role in providing guidance to make sure that the facility is compliant.

The meeting concluded and no further questions were asked by the Administrator.

Exit interview was conducted with Administrator, Asenaca Ranitu and a copy of this report was emailed for signature.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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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