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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602265
Report Date: 03/13/2025
Date Signed: 03/13/2025 02:32:06 PM

Document Has Been Signed on 03/13/2025 02:32 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:SHADY ACRES GUEST HOMEFACILITY NUMBER:
198602265
ADMINISTRATOR/
DIRECTOR:		WILLIAMS, CHRISTINEFACILITY TYPE:
735
ADDRESS:901 N LOS ROBLES AVETELEPHONE:
(626) 356-9168
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 10CENSUS: 6DATE:
03/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Amada Castenda, CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:18 PM
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Licensing Program Analyst (LPA) Sanjay Vaid conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement Tool to evaluate the facility. LPA Vaid met with DSP Amada Casterndea and Doisline Espinel who allowed entry, LPA explained the purpose of the visit. DSP Amada Castenda assisted with the visit .

The facility is licensed to serve 10 ambulatory developmentally disabled clients aged 18 to 59. Currently, there are six (6) clients in placement and receive case management services provided by Frank D Lanterman Regional Center.

1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has Infection Control Plan and Mitigation Plan. Bathrooms have hand washing signs, soap and paper towels. Per Facility Administrator all staff also have the COVID-19 vaccines including boosters. Facility Administrator is adhering to infection control requirements.

2.Operational Requirements: Fire Drills are conducted every three months with all clients present in the home. Emergency Disaster/ Earthquake Drills are conducted every quarter.

3.Physical Plant & Environment Safety: The home is a two-story facility includes a living room, dining room, kitchen, laundry room, 5 client bedrooms, 2 restrooms, an unattached garage and indoor/outdoor activity areas. LPA observed appropriate furniture, lighting fixtures, personal storage space as required, all beds have adequate amount of linen and mattresses, and box springs are in good repair.
Continued on 809C.......
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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 3
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: SHADY ACRES GUEST HOME
FACILITY NUMBER: 198602265
VISIT DATE: 03/13/2025
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Bathrooms have skid mats and shower chair and were found to be within Title 22 regulations. Toilets and water faucets worked properly. Bathroom sinks and showers were free of mold/mildew. LPA observed that sufficient toiletries accessible to clients. Water temperature measured between 107.9- 116-4 degrees F which is within range of 105.0 – 120 Degrees F. Facility temperature was within required range. LPA observed the facility to be clean and appropriately furnished. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detectors interconnected and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher(s) are fully charged. Exit, walkways and/or passageways, front yard is free of debris and back yard are not free of debris and/or hazards. Exits are marked with visible signs. Notifications and postings were observed which included personal rights, visitor policy, complaint procedures, menu, and emergency disaster plan in the hallway.
4.Staffing: There is sufficient staffing at the facility at all times. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.
5. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and S1-S2. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator Certificate expired on 12/13/2024, and certificated renew is in process.
6.Client Rights-Information: Client personal rights and House Rules are posted. Per Facility Administrator, facility provides wi-fi services for facility clients.
7. Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Mental Health Intake assessment, special Incident reports, Client Personal Property and Clients Personal Rights and current IPPs.
8. Food Service: The facility has sufficient food supplies of 2-day perishable and 7 day supply of non-perishable items. The food is properly stored in the refrigerator which is clean and well maintained. There are no clients with special diets residing at this facility. Kitchen is kept clean and free from rodents and other bugs/ insects. Plates, cups and utensils are kept cleaned and stored properly.

Continued on 809C......
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: SHADY ACRES GUEST HOME
FACILITY NUMBER: 198602265
VISIT DATE: 03/13/2025
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9. Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1-C4. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly.
10. Incidental Medical Services: Per Facility Administrator, there are no clients at this home with incidental medical services or restricted health condition.
11. Disaster Preparedness: The facility has an Emergency Disaster Plan.
12. Emergency Intervention: Not Applicable.

No deficiencies were found on today’s visit. Exit interview is conducted and a copy of this report, was provided to DSP Amada Castaneda.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
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