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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602536
Report Date: 09/24/2024
Date Signed: 09/24/2024 12:39:36 PM

Document Has Been Signed on 09/24/2024 12:39 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/
DIRECTOR:		NANONG-YRIGOYEN, KIMBERLYFACILITY TYPE:
775
ADDRESS:180 N VINEDO AVETELEPHONE:
(626) 773-7254
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 75CENSUS: DATE:
09/24/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:02 PM
MET WITH:Kimberly Yrigoyen - Administrator TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced Plan of Correction visit at the facility to follow on deficiencies noted during annual visit. LPA met with Kimberly Yrigoyen and explained the reason for the visit.

On 7/16/24 LPA Flores conducted an annual inspection visit. During this visit LPA provided the following deficiencies:

Section - CCR 82064(d) Administrator -Qualifications and Duties: On 7/16/24 LPA observed administrator did not meet the 30 hours requirement of continuous education. On 7/29/24 Administrator submitted 15 hours of training to the department and on 8/21/24 administrator submitted additional 15 hours of training to the department. Deficiency cleared as of 8/21/24.

Section - CCR 82068.2(d)(1) Needs and Services Plan: On 7/16/24 three (3) clients were missing current Individual Progress Plans (IPP). On 7/29/24 Administrator submitted copies of current IPPs for two (2)clients and a plan from Regional Center to conclude one (1) IPP. Deficiency cleared as of 7/29/24.

Deficiencies cleared.

Exit interview was conducted with Kimberly Yrigoyen and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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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