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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602265
Report Date: 03/10/2023
Date Signed: 03/10/2023 03:13:04 PM

Document Has Been Signed on 03/10/2023 03:13 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: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: DATE:
03/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Staff S1TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 03/10/2023 at 9:07 am. LPA was met by Staff S1 and explained the purpose of the visit. Facility is licensed to residents 18 to 59 years old. The facility has a fire clearance approved for ten (10) ambulatory. There are seven (7) level 3 developmentally disabled clients residing at this facility. Residents at this facility are receiving services from Frank D Lanterman Regional Center. LPA requested and obtained a copy of Personnel Report (LIC 500), and Resident Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at 10:02 am and was led Staff S1. The Facility is a two-story building located in a residential area with five (5) client shared bedrooms, two (2) client shared bathrooms, two (2) living rooms, kitchen, dining room, front yard, backyard and two (2) detached car garage.

· Front Yard: Was clean and well maintained. No hazards were observed.

· Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. Kitchen sink water temperature was measured at 110.3 degrees F. At 10:10 am, LPA observed knives and sharps located in kitchen cabinet to the left of sink, to be accessible to 7 out of 7 clients in care. Several bottles of disinfectants and cleaning solutions were observed near washer and dryer and were accessible to 7 out of 7 clients in care.

· Dining Room/Living room: Dining room was observed to be clean and contained one table and 7 chairs. Living room was observed to contain 1 couch, 2 recliners TV and plenty of lighting. Thermostat located near living room was observed at 74 degrees F.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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 7
Document Has Been Signed on 03/10/2023 03:13 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 03/10/2023 at 01:01 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: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, disinfectants and cleaning solutions were observed near laundry area floor and accessible, knives and sharps located in kitchen cabinet were observed to be accessible, the licensee did not comply with the section cited above in which 7 out of 7 clients; poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2023
Plan of Correction
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Licensee/Administrator will re-train staff on proper procedures for safeguarding such disinfectants and cleaning solutions. Licensee will submit via email, proof of training material, and staff acknowledgement of training. Staff S1 removed products during tour and secured them in garage, which is inaccessible to residents.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 03/10/2023 03:13 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 03/10/2023 at 01:01 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: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)(2)(B)
Infection Control Requirements
A licensee shall ensure that infection control practices are maintained as follows:  (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (B) Walls and window coverings in resident care areas shall be dusted or cleaned on a regular schedule or when they are visibly contaminated or soiled. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, window blinds located in dining room area by sliding door were observed to have brownish spatter and dirt, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to 7 out of 7 persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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Licensee/Administrator will clean and maintain all blinds and window coverings. Photo proof of cleaned blinds located by sliding door must be submitted.
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, shared bathroom #2 light fixture on/off button is stuck and light does not stay on, shared client bedroom #4 closet door is broken,shared client bedroom #4 (unoccupied) bed frame is broken,base board walls throughout the home were observed to be dirty and conatin dust, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to7 out of 7 persons in care.
POC Due Date: 03/24/2023
Plan of Correction
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Licensee/Administrator will fix light fixture in shared bathroom #2, repair or replace closet door, bed frame and dresser drawer in shared client bedroom #4, and clean base boards and walls throughout facility. Photo proof must be submitted via email. During visit bedroom #4 broken bed frame was removed and roon is now private.
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:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/10/2023 03:13 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 03/10/2023 at 01:01 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: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA did not have access to staff files and staff files were not located at facility site, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to 7 out of 7 persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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Licensee/Administrator will develop a back-up plan to ensure all personnel records are accessible to this licensing agency or are maintained at facility site. Proof of back plan is required via email to LPA.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


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Document Has Been Signed on 03/10/2023 03:13 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 03/10/2023 at 01:11 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: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)
Acceptance and Retention Limitations. If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request

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 above in that there are a total of 4 clients over the age of 59, and an Exception Waiver for clients is not in place. In the past there were 3 clients over the age of 59; at that time and Exception Waiver was not needed. However, now the census exceeds 50% of allowable residents over the age of 60, which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 03/24/2023
Plan of Correction
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Administrator shall submit an Age Exception request for C3, C4, C5, and C7 by POC due date, and/or one of the clients shall be relocated. If an extension is required, submit a written request by the due date.

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:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


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: SHADY ACRES GUEST HOME
FACILITY NUMBER: 198602265
VISIT DATE: 03/10/2023
NARRATIVE
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·2nd floor Living room: LPA observed area to be clean and contain a TV, plenty of seating and lighting.

1st Floor Client Rooms 1 - 2: All contained the required furnishings, linens and were observed to be clean. Client bedroom #1 and #2 are shared.

· 1st floor Shared Bathroom# 1: Shared resident bathroom# 1 was observed to be clean and contained soap and paper towels. Signs promoting handwashing were observed. Water temperature in this bathroom was measured at 113.7 degrees F which is in the required 105 – 120 degrees F.

· 2nd Shared Client bathrooms# 2: Water temperature in client bathroom #1 was measured at 116.9 degrees F. Grab bars and non-slip mats were observed in shower.

· Centrally Stored Medications: LPA’s observed cabinet located in 1st floor hallway to be locked and inaccessible to residents. LPA reviewed 7 client Medication Administration Records (MAR).

· Garage: LPA observed extra bedding supplies, cleaning products and hygiene products. Garage was locked and inaccessible to residents.

· Backyard: Clean and free from hazards. LPA observed plenty of seating and shade.

LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit. Administrator certificate was observed for Asenaca Ranitu with an expiration date of 09/22/24. Last fire drill was conducted on 02/22/23. LPA was unable to review staff files due to staff files not being at facility.

Deficiencies are being cited during visit. Exit interview was conducted with Administrator Hernandez and a copy of this report and appeals rights was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC809 (FAS) - (06/04)
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