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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602896
Report Date: 07/07/2023
Date Signed: 07/08/2023 09:44:00 AM

Document Has Been Signed on 07/08/2023 09:44 AM - 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: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: 25DATE:
07/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Carolee HazzardTIME COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 07/7/2023 at 12:56am. LPA was met by Licensee Carolee Hazzard and explained the purpose of the visit. Facility is licensed to serve clients 18- 59 years old.

LPA OBSERVATIONS: Tour began at 9:15am and was led by licensee. The facility is a two-story building located in a residential area with seventeen (17) client bedrooms, five (5) bathrooms, one (1) staff bathroom, one (1) staff office, kitchen, dining room, living room, two (2) tv/lounge rooms, front yard, backyard, and detached garage.

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

Kitchen: LPA Ramirez observed food debris on floor near stove, brownish-yellow stains on walls near kitchen stove and surrounding walls in kitchen. LPA Ramirez observed staff preparing food for lunch without gloves. LPA Ramirez observed flies and insects crawling over a 15lb to 20lb bag of potatoes on the floor. LPA Ramirez observed insects crawling in kitchen cabinets. Kitchen cabinets that contained plates, cups, mixing bowls and other dishware, were missing doors.LPA Ramirez observed kitchen refrigerator to be dirty and contain food debris in and around the refrigerator floor. Inside refrigerator side doors were observed to be held with black duck tape. LPA Ramirez did not observe required two day minimum of perishables and seven day minimum of non-perishables on premises. Title flooring were observed in this area and throughout the facility to be missing laminate tiles. Water temperature in kitchen sink was measured at 132.5 degrees F. LPA Ramirez observed staff place a pad lock on kitchen door after lunch service.

Dining Room/Living room: Dining room tables were observed and contained plenty of seating. Living room was observed plenty of seating and lighting. LPA Ramirez observed fully charged fire extinguisher in this area. Missing/broken laminate tiles were observed in this area.

SEE 9099-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
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 11
Document Has Been Signed on 07/08/2023 09:44 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/07/2023 at 03:19 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: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interview, the licensee did not comply with the section cited above in 25 out of 25 clients, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2023
Plan of Correction
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Licensee will certify plan to address installing carbon monoxide detectors in the facility that meet established standards. Picture proof of installed carbon monoxide detectors must submitted via email by 7/14/23.
Type A
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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4
Based on observation,kitchen walls, hallway walls, dining room walls, dining room ceiling fan, client bathroom #1 sink was not operable, missing laminet flooring tiles throughout facility, missing door knob in room #5, room# 13 door is cracked and chipped at the door knob and outlet cover in room is missing, room# 14 cracks in wall, room #16 hole in wall 5x5, hole in hallway wall across from staff office, room #16 dresser is missing 2 out of 5 drawers, the licensee did not comply with the section cited above in 25 out of 25 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Licensee will clean, sanitize and repair and/or replace dresser, operable sink in client bathroom #1, door, and wall(s). Licensee will develop and maintain a facility cleaning log for the next 30 calendar days.
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: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 07/08/2023 09:44 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/07/2023 at 03:19 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: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)(1)
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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, LPA Ramirez observed several flies and insects crawling in kitchen and throught the facility, the licensee did not comply with the section cited above in 25 out of 25 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2023
Plan of Correction
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Licensee will develop a plan to address insect infestation and flies. Licensee will provide contract of pest control services to keep the facility free from flies and insects. Proof must be provided by 7/14/23 via email to LPA Ramirez.
Type A
Section Cited
CCR
80087(b)(1)
Building and Grounds
(b) All clients shall be protected against hazards within the facility through provision of the following: (1) Protective devices including but not limited to nonslip material on rugs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA Ramirez did not observe non slip material on bathroom rugs,and/or non slip mats in bathroom showers and tubs, the licensee did not comply with the section cited above in 25 out of 25 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2023
Plan of Correction
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Licensee will devlop plan to address how the facility will meet requirement. Licensee will send picture proof of non slip material or mats in showers and/or tubs.
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: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 07/08/2023 09:44 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/07/2023 at 03:19 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: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, client bathroom #4 hot water was not delievering hot water, the licensee did not comply with the section cited above in 25 out of 25 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2023
Plan of Correction
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Licensee will devleop plan to address lack of hot water in client bathroom #4. Licensee will send video proof of hot water faucet working by 7/14/23.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain 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:
Deficient Practice Statement
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Based on observation, client bathrrom #2, 3, 5, all had water temperature reading above 120 degrees F, the licensee did not comply with the section cited above in 25 out of 25 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2023
Plan of Correction
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Licensee will adjust water temperature to meet requirements. Licensee will maintain a water log for the next 7 calendar days and record water temperatures every 12 hours. Proof of water log must be submitted via email by 7/14/23.
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: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 07/08/2023 09:44 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/07/2023 at 03:19 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: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (2) Taps delivering water at 125 degrees F (51.6 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, water temperature in kitchen was measuring at 135. 6 degrees F, the licensee did not comply with the section cited above in 7 out of 7 staff and visitors, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2023
Plan of Correction
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 Licensee agreed to turn down hot water during visit.
Type A
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 5 out of 5 client bathrroms observed were dirty and missing tiles in shower/tub area, exposed drywall, smell of urine, the licensee did not comply with the section cited above in 25 out of 25 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2023
Plan of Correction
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Licensee will clean and sanitze all client bathrooms by 7/8/23. Licensee will develop plan to address how facility will make repairs to client bathrooms by 7/8/23. Licensee will send receipt of repairs or proof of contract to make repairs via email by 7/14/23.
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: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 07/08/2023 09:44 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/07/2023 at 03:19 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: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, 4 out of the 5 client bathrooms did not have a container to throw away solid waste, LPA Ramirez observed solid waste napkins thrown on floor near toilet, the licensee did not comply with the section cited above in 25 out of 25 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2023
Plan of Correction
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2
3
4
Licensee will provide containers in bathroom to dispose of solid waste.
Type A
Section Cited
CCR
85088(e)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA did not observe any emergency lighting the licensee did not comply with the section cited above in 25 out of 25 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2023
Plan of Correction
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2
3
4
Licensee will develop plan to address emergency lighting by 7/8/23. Licensee will maintain emergency lighting as required and submitt receipts by 7/14/23.
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: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 07/08/2023 09:44 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/07/2023 at 03:19 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: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(1)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA Ramirez observed insects crawling inside a bag of potaoes that was laying on the floor of the kitchen, the licensee did not comply with the section cited above in 25 out of 25 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2023
Plan of Correction
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2
3
4
Licensee will remove stored food from floor. Licensee will re-train staff on how to properly store perishable foods.
Type A
Section Cited
CCR
80076(a)(4)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (4) Between meal nourishment or snacks shall be available for all clients unless limited by dietary restrictions prescribed by a physician.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, LPA Ramirez observed staff place a pad lock on entry to kitchen, the licensee did not comply with the section cited above in 25 out of 25 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2023
Plan of Correction
1
2
3
4
Licensee will remove padlock.
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: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 07/08/2023 09:44 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/07/2023 at 03:19 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: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(13)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (13) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, staff was handling food without gloves, the licensee did not comply with the section cited above in 25 out of 25 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2023
Plan of Correction
1
2
3
4
Licensee will develop plan to re-train staff on food preperation and service by 7/8/23. Licensee will ensure staff follow personal hygiene and food services sanitation practices. Proof of staff attendance must be submitted to LPA by 7/14/23.
Type A
Section Cited
CCR
80076(a)(17)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA observed what appeared to be rodent droppings behind freezer, and food debris in and around kitchen, the licensee did not comply with the section cited above in 25 out of 25 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2023
Plan of Correction
1
2
3
4
Licensee will develop plan to address rodent droppings and food debris in kitchen area. Proof of pest control must be submitted via email by 7/14/23.
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: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 07/08/2023 09:44 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/07/2023 at 03:19 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: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA Ramirez did not observe required nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises, the licensee did not comply with the section cited above in 25 out of 25 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2023
Plan of Correction
1
2
3
4
Licensee will submit receipt of required food supply by 7/8/23 via email.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 07/08/2023 09:44 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/07/2023 at 03:19 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: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) In all facilities with a licensed capacity of 16 or more clients, and all facilities having separate floors or separate buildings without full-time staff there shall be a signal system which has the ability to meet the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, LPA Ramirez did not observe required signal system, the licensee did not comply with the section cited above in 25 out of 25 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
1
2
3
4
Licensee will re-install signal system on facility premises and maintain them in working order.
Type B
Section Cited
CCR
85088(f)(1)(A)
Fixtures, Furniture, Equipment, and Supplies
(1) In all facilities with a licensed capacity of 16 or more clients, and all facilities having separate floors or separate buildings without full-time staff there shall be a signal system which has the ability to meet the following requirements: (A) Operation from each client's living unit.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
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Based on observation and interview, LPA Ramirez did not observe required signal system,the licensee did not comply with the section cited above in 25 out of 25 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Licensee will re-install signal system in client's bedrooms and maintain them in working order.
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: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


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: PASADENA GUEST HOME
FACILITY NUMBER: 198602896
VISIT DATE: 07/07/2023
NARRATIVE
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Client Rooms: LPA Ramirez selected eight client bedrooms at random to inspect. Bedrooms #2,3,5,11,13,14,15,16 all contained required furnishings, linen, and lighting. LPA Ramirez observed a hole that exposed dry wall in hallway near staff office. client room #5 has missing blinds and entry door dead bolt was missing, client room #13 entry door was cracked and missing pieces of wood near dead bolt lock and outlet cover was missing on outlet behind entry door, client bedroom #14 had cracks in walls which exposed dry wall, client bedroom #16 contained a 5x5 inch hole in wall, no signal systems were observed in any client bedrooms.

Bathrooms: LPA Ramirez observed 1st floor client bathroom#1 to not be fully operating. LPA Ramirez observed a sign placed on sink that said "do not touch this means you". LPA Ramirez could not test water in this bathroom and sink was not operable. Client Bathroom #1 was observed to be dirty with caked black grime on walls and near toilet, yellowish stains on toilet bowl, and missing shower tiles in throughout bathroom shower. Client bathrooms #2, 3, 4 and 5 were all observed to be dirty with caked grim on bathroom tiles, rubbish and litter on floor, no bins with lids or containers were observed for storage of solid waste. LPA Ramirez did not observe toilet paper, hand soap, or paper towels in any client bathrooms. Client bathroom #2 water temperature was measured at 125.4 degrees F. Client bathroom #3 was measured at 127.8 degree F. Client bathroom #4 hot water knob was not operable during visit. Client bathroom #5 water temperature read at 129.6 degrees F.

Backyard: No hazards were observed

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher: LPA Ramirez did not observe carbon monoxide detectors in the facility. LPA Ramirez observed and tested smoke detectors throughout the facility. LPA Ramirez observed several fully charged fire extinguishers in the facility. LPA did not observe flashlights or other battery operated lighting. LPA Ramirez did not observe a working signaling system in the facility.

Deficiencies are being cited. Exit interview was held with Licensee Hazzard and a copy of this report, 9099-D and appeals rights was provided.

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

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
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