198602896-6-10-2026-28-AS-MCOA-DUWVXY-20260610165021

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602896
Report Date: 06/10/2026
Date Signed: 06/10/2026 05:08:56 PM

Document Has Been Signed on 06/10/2026 05:08 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 HOME		FACILITY NUMBER:	198602896
ADMINISTRATOR/ DIRECTOR:	HAZZARD, CAROLEE		FACILITY TYPE:	735
ADDRESS:	1025 N. LOS ROBLES AVENUE		TELEPHONE:	(626) 798-0869
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY: 30		CENSUS: 26	DATE:	06/10/2026
TYPE OF VISIT:	Office	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Carolee Hazzard, Administrator and Debbie Meyers, Evening Supervisor		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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A Non-Compliance Conference (NCC) was held today at the Monterey Park Adult and Senior Care Licensing office. Tony Vasallo, Regional Manager (RM), Monica Tran, Regional Manager, Adeline Ho, Licensing Program Manager (LPM) and, Mayra Cota, Licensing Program Analyst (LPA), met with Carolee Hazzard, Administrator and Debbie Meyers, Evening Supervisor, and the reason for the conference was explained.

During the office meeting the following was discussed:

Facility has excessive deficiencies which have not been corrected between 4/14/2026 – 5/22/2026.

Facility has received Civil Penalties for the following sections:

· CCR 80019(e)(3) $1,000 for Caregiver Background Check
· CCR 80075(b) $1,100 for Failure to Correct on 5/5/2026.
· CCR 80087(a) $250 for Repeat Violation on 5/22/2026.
· HSC 1565(a) $700 for Failure to Correct on 5/22/2026.

Staffing concerns:
· Facility may not have sufficient staff on shift to provide care and supervision for clients.
· One staff member on shift to care and supervise 25 clients at once.
· Administrator indicated that she has not been able to take clients to receive a medical assessment and does not have anyone who can assist with taking clients to see a doctor.
· Lack of staff training: none of the staff working at the facility had First Aid/CPR certification.
· Administrator certificate is expired and does not have HIV/TB training. ***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: 06/10/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

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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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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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: 06/10/2026

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Staff’s inability to access second story of the home.
· During annual visit conducted on 4/23/2026, staff were unable to conduct tour of the second floor with LPA, due to insufficient staffing being on shift.

Medication administration management:
· During visit on 4/23/2026, expired medication was being given to a client. Also observed, several clients were given medication at the wrong time.
· Staff indicated that medication is not administered at the time indicated by prescription because clients are having side effects.
· Physicians have not been notified regarding client reactions to their current medication.
· Medications not given as prescribed.

Concerns for the condition of the physical plant.
· Complaint investigation # 28-AS-20260430152031 conducted on 5/5/2026 by LPA Konishi – showers being in disrepair.
· Complaint investigation # 28-AS-20260407083604 conducted on 5/12/2026 by LPA Mallett – facility being in disrepair/showers and toilets not working, rotting floor tiles, no heating available. Facility does not have enough bathrooms for the number of clients living at the facility.
· Complaint investigation # 28-AS-20260515104359 conducted on 5/22/2026 by LPA Cota – facility being in disrepair/hand railing.
· Complaint investigation #28-AS-20260423163727 conducted on 4/30/2026 by LPA Vaid – mattresses not being discarded and unclean oven, stove and exhaust. This complaint expresses concerns regarding inability to maintain fire clearance due to expired fire extinguishers, missing smoke detectors in clients’ bedrooms, outdated fire sprinklers and fire system signal lights not working properly.
· Kitchen walls have accumulated grease and mildew.

***LIC 809-C page 3***

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/10/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

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: 06/10/2026

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Licensee was provided with the following:
80053 Follow-up Visits to Determine Compliance
80063 Accountability
80064 Administrator - Qualifications and Duties
85064 Administrator Qualifications and Duties
80065 Personnel Requirements
85065 Personnel Requirements
85078 Responsibility for Providing Care and Supervision
LIC 311C Records to be maintained at the facility
LIC 308 Designation of Facility Responsibility
Licensee agrees to accept Technical Support Program (TSP) services. TSP services were requested on 5/28/2026 for the following areas:
· Physical Plant
· Medication management
· Staff training

Licensee agrees to clear the below citations by:

· Section 80087(a) Building and Grounds: Area around the stove and on the hood vent was observed with grease and mildew. POC was due on 5/22/2026. Licensee will correct and send proof by 6/15/2026.
· Section 80069(b) Client Medical Assessment: clients are not current on their medical assessment. POC is due on 6/15/2026. Extension request was provided by Licensee during the meeting. Licensee will provide proof of correction by 7/8/2026.
· Section 80087(a) Building and Grounds: facility stairwells and staircase have handrails in disrepair. POC was due on 5/8/2026. Licensee will send proof of correction by 6/15/2026.
· Section 85095.5(a)(2)(B) Infection Control Requirements: windowsills in (2) living room windows and (2) windows in the office were observed unclean. POC was due on 6/5/2026. Licensee will send proof of correction by 6/15/2026.
***Continues on LIC 809-C page 2****

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/10/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

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: 06/10/2026

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Section 85064(b) Administrator Qualifications and Duties: staff has not renewed their administrator certificate. POC due date is 6/30/2026.
· Section 1565(c) Other Provisions: facility has not conducted safety drills. POC was due on 6/2/2026. Licensee will correct by 6/15/2026.
· Section 85064(k) Administrator Qualifications and Duties: staff does not have HIV and TB training. POC is due on 6/30/2026.

Licensee agrees to hire part-time staff to assist the administrator with care and supervision of clients, documentation and cleaning by 7/30/2026 and also provide an updated LIC 500 Personnel Report.
Licensee will provide LIC 308 Designation of Facility Responsibility by: 6/15/2026.
Failure to comply will result in administrative action.

Exit interview was conducted and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/10/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

LIC809 (FAS) - (06/04)

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