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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602896
Report Date: 07/20/2022
Date Signed: 07/20/2022 01:01:07 PM

Document Has Been Signed on 07/20/2022 01:01 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PASADENA GUEST HOMEFACILITY NUMBER:
198602896
ADMINISTRATOR:HAZZARD, CAROLEEFACILITY TYPE:
735
ADDRESS:1025 N. LOS ROBLES AVENUETELEPHONE:
(626) 798-0869
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 30CENSUS: 22DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carolee Hazzard, administratorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arrival, LPA met with Administrator Carolee Hazzard, who assisted with visit. The facility is licensed to serve 30 ambulatory clients, ages 18-59. Annual fees are current. LPA discussed with administrator regarding the purpose of today's visit and the inspection.

During the visit, the following domain of the new inspection tool was used: infection control domain; a tour of the facility was conducted; food supply was reviewed; and medications were reviewed.

The facility is a two-story house located in a residential neighborhood and consists of living room, dining area, kitchen, laundry room, seventeen (17) bedrooms and six (6) bathrooms. Facility maintains the required two (2) days perishable and seven (7) days non- perishable. Clients’ bedrooms have beds, dresser, and closet space available. Adequate linen and personal hygiene supply are observed. Lamps/lights for each room are available to ensure the safety and comfort of all persons in the facility. Backyard has a covered trash can. Smoke detectors are operable. Medications are centrally stored and locked.

(-continued in LIC 809C-)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASADENA GUEST HOME
FACILITY NUMBER: 198602896
VISIT DATE: 07/20/2022
NARRATIVE
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Medications are properly logged and current. Hazardous items are locked and inaccessible to clients. Fire extinguishers are fully charged. Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils are stored. The front yard is well maintained. No pools or large bodies of water at the facility. Passageways are free of obstruction. Last disaster drill was conducted on 01/07/22

Deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6.

An exit interview was conducted. This report was discussed and provided to Administrator, whose signature on this form confirm receipt of these documents. Appeal right was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/20/2022 01:01 PM - It Cannot Be Edited


Created By: Bonnie Tao On 07/20/2022 at 11:56 AM
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: PASADENA GUEST HOME
FACILITY NUMBER: 198602896

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
(e) (1) Hot water temperature controls shall be maintained to automatically regulate temperature... a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Hot water temperature is measured at 170.5 degrees Fahrenheit.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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Administrator will ensure the water temperature will remain in a range of 105 - 120 degree Fahrenheit; A water temperature log dated 7/21/22 will provide to Licensing. Plan of Corrections (POC) must be corrected by POC date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/20/2022 01:01 PM - It Cannot Be Edited


Created By: Bonnie Tao On 07/20/2022 at 12:40 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: PASADENA GUEST HOME
FACILITY NUMBER: 198602896

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(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:
No carbon monoxide detectors at the facility.
Bathroom #1 on 1st floor and Bathroom #6 on 2nd floor are in disrepair since the flooring tiles are missing.
Resident Room #13’s door nob is missing.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
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Administrator will install carbon monoxide detector at the facility, a door nob in resident room #13 and flooring tiles in resident bathroom#1 and #6 by the POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022


LIC809 (FAS) - (06/04)
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