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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602896
Report Date: 04/23/2026
Date Signed: 04/23/2026 06:28:11 PM

Document Has Been Signed on 04/23/2026 06:28 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:PASADENA GUEST HOMEFACILITY NUMBER:
198602896
ADMINISTRATOR/
DIRECTOR:		HAZZARD, CAROLEEFACILITY TYPE:
735
ADDRESS:1025 N. LOS ROBLES AVENUETELEPHONE:
(626) 798-0869
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 30CENSUS: 25DATE:
04/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA met with Carolee Hazzard, Administrator, and the reason for the visit was explained.

The facility is licensed to serve 30 ambulatory clients, ages 18-59. There are currently 25 clients living in the facility. The facility is a two-story home located in a residential area of Pasadena. During arrival to the facility, Carolee Hazzard was the only staff on shift. Hazzard indicated that today’s census is 25 and no other staff will be present to provide care and supervision to residents till 3:00 p.m. Hazzard proceeded to facilitate the tour of the first floor of the home.

The facility consists of the following: First floor: living room, office, (7) client bedrooms, a kitchen, a (2) dining rooms, pantry and (3) bathrooms. Second floor: laundry room, (10) client bedrooms, (3) bathrooms, (2) sitting rooms. Front and backyard, patio area and detached garage.

During today’s visit, LPA observed the following:


  • Client bedrooms have clean bedding and the required furniture.
  • Walkways, passages and exits are free of debris and obstruction.
  • Dining rooms have sufficient seating. Kitchen appliances are kept clean, however, area around the stove and on the hood vent observed with grease and mildew. knives and cleaning solutions were observed in an unlocked cabinet in the kitchen, accessible to clients. The facility has sufficient 2-day non-perishable and 7-day non-perishable food.
***Continues on LIC 809-C***
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2026
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 8
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/23/2026 06:28 PM - It Cannot Be Edited


Created By: Mayra Cota On 04/23/2026 at 02:50 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: 04/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to knives and cleaning solutions being in an unlocked cabinet in the kitchen and accessible to clients, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2026
Plan of Correction
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Knives and cleaning solutions were locked by staff during visit. Corrected during visit.
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

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 due to Staff #5 and #6 not being associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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Administrator will complete Criminal Record Exemption Transfer Request (LIC 9188) and sent to CTMB for Staff #5 and Staff #6 by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/23/2026 06:28 PM - It Cannot Be Edited


Created By: Mayra Cota On 04/23/2026 at 02:50 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: 04/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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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Based on observation, the licensee did not comply with the section cited above in that area around the stove and on the hood vent was observed with grease and mildew which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2026
Plan of Correction
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Administrator will conduct a deep clean/removal of all grease and mildew on the stove, walls, and hood vent and send LPA photos by POC due date.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 [6] out of [6] do not have First Aid/CPR certification, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2026
Plan of Correction
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Administrator will schedule training for Staff 1 - Staff 6 and send proof of certification by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/23/2026 06:28 PM - It Cannot Be Edited


Created By: Mayra Cota On 04/23/2026 at 02:50 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: 04/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

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 [7] out of [8] clients do not have a current Physician's Report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2026
Plan of Correction
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Administrator will obtain and email LPA, current copies of Physician Reports for Resident 2 - Resident 8 by POC due date.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 that the facility does not have a current Emergency and Disaster Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
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Administrator will email LPA a copy of their Emergency and Disaster Plan LIC 610-D.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2026


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASADENA GUEST HOME
FACILITY NUMBER: 198602896
VISIT DATE: 04/23/2026
NARRATIVE
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  • Water temperature from bathrooms sinks was tested and measured between 117.1 - 119.1, which is within compliance range. Seven (8) smoke detectors on the first floor were tested and were observed to be working properly. Three (3) fire extinguishers were also observed on the first floor and are kept charged and operational.
  • Six (6) staff files were reviewed. Review of staff files indicated that Staff #5 and #6 are not associated to the facility. Review also indicated that (6) out of (6) staff do not have First Aid/CPR certification.
  • Eight (8) client files were reviewed. (7) out of (8) client files do not have a current Physician’s Report. Facility does not have an Emergency and Disaster Plan.

Review of medication was conducted, and the following observations were made: Client 1 has expired medication which according to S1 has been given to client as part of their daily regimen. The medication is Hydroxyzine HCL 25 mg tablets which expired on 12/2025.
Client 2 has been given their AM medication in the evening and their PM medication in the morning. The medication given at the incorrect times are (1) morning tablet of Hydrocortisone 5 mg and (2) evening Hydrocortisone 5 mg tablets.
Client 3 was given evening medication earlier than prescribed. Client 3’s bedtime Atorvastatin 10 mg tablet was given in the morning on 4/23/2026.
Client 4 had several missed doses for 4/23/2026. Client 3’s Divalproex SOD ER 250 mg, Vitamin D3 2,000 unit (50MCG), Ferrous Sulfate 325 mg and Trihexyphenidyl 2 mg tablets were not given to client in the morning.

Due to time constraints, an annual continuation visit will take place at a later time. During today's visit, deficiencies were noted and citations issued. Civil Penalty was assessed for $1000.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 04/23/2026 06:28 PM - It Cannot Be Edited


Created By: Mayra Cota On 04/23/2026 at 04:50 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: 04/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in Client 1 has expired medication which according to S1 has been given to client as part of their daily regimen. The medication is Hydroxyzine HCL 25 mg tablets which expired on 12/2025.
Client 2 has been given their AM medication in the evening and their PM medication in the morning. The medication given at the incorrect times are (1) morning tablet of Hydrocortisone 5 mg and (2) evening Hydrocortisone 5 mg tablets.
Client 3 was given evening medication earlier than prescribed. Client 3’s bedtime Atorvastatin 10 mg tablet was given in the morning on 4/23/2026.
Client 4 had several missed doses for 4/23/2026. Client 3’s Divalproex SOD ER 250 mg, Vitamin D3 2,000 unit (50MCG), Ferrous Sulfate 325 mg and Trihexyphenidyl 2 mg tablets were not given to client in the morning. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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Administrator will email LPA a plan on how to manage clients medication appropriately. Administrator will plan on completing training medication administration, and destruction and will send LPA proof of scheduled training.
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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2026


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 04/23/2026 06:28 PM - It Cannot Be Edited


Created By: Mayra Cota On 04/23/2026 at 05:30 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: 04/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(a)
80065(a) Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above in that during arrival to the facility, the administrator was the only staff on shift. Staff indicated that today’s census is 25 and no other staff will be present to provide care and supervision to residents till 3:00 p.m. Staff was unable to to facilitate the tour of the first floor of the home due to not having another staff to assist LPA, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2026
Plan of Correction
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Administrator will provide the department a plan on how to maintain sufficient staffing to provide care and supervision to clients in care. Administrator will send LPA, a current LIC 500 with the current schedules for each staff. Administrator will also send a plan on assigning a back up person to be at the facility when administrator cannot attend.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2026


LIC809 (FAS) - (06/04)
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