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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602536
Report Date: 08/08/2023
Date Signed: 08/08/2023 02:38:56 PM

Document Has Been Signed on 08/08/2023 02:38 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:SVS PASADENAFACILITY NUMBER:
198602536
ADMINISTRATOR:NANONG-YRIGOYEN, KIMBERLYFACILITY TYPE:
775
ADDRESS:180 N VINEDO AVETELEPHONE:
(626) 773-7254
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 75CENSUS: 51DATE:
08/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Kimberly Yrigoyen - AdministratorTIME COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Kimberly Yrigoyen - Facility's Director and explained the reason for the visit.

Facility is licensed to served as an Adult Day Program with a capacity of 75 adults in the age range of 18 years and over, of which 60 adults may be ambulatory and 15 adults may be non-ambulatory. Facility has a lobby/locker/waiting room area, a conference room, 7 offices, an isolation room, a computer room, a media room, kitchen, gym, styling room, art room, staff break room, library, 4 restroom and 2 changing rooms.

LPA Flores conducted a tour with administrator and observed the following:
Facility is in good repair throughout. A fire sprinkler system was observed throughout and was last inspected on 1/23. Kitchen area was observed clean, refrigerator is used to store clients' lunch. No chemicals were observed. Sharps were observed locked in a cabinet. Each restroom (4) is clean and in working condition, water temperature was tested in each restroom between 104.1 - 105.2 degrees F., which is within the required 105-120 degrees F. First Aid kits were observed in three different areas with all the required items. Fire Extinguishers were last review on 8/1/23. Last fire drill was conducted on 5/4/23.

LPA reviewed 5 staff and 5 client files. Individual Program Plan for client #5(C5) was dated: 9/27/16 and is not current.

Deficiency noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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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Document Has Been Signed on 08/08/2023 02:38 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/08/2023 at 02:00 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: SVS PASADENA
FACILITY NUMBER: 198602536

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(d)(1)
Needs and Services Plan
(d) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that: (1) The needs appraisal or IPP is not more than one year old.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in C5 last IPP on file isdated 9/27/16 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2023
Plan of Correction
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Administrator will obtain a current copy of IPP and submitted to the department by POC due date 8/22/23.
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:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


LIC809 (FAS) - (06/04)
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