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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602896
Report Date: 07/08/2023
Date Signed: 07/08/2023 03:02:06 PM

Document Has Been Signed on 07/08/2023 03:02 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: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:
07/08/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Carolee HazzardTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Continuation Visit on 07/08/2023 at 9:48am, stemming from initial Annual Required Visit on 07/07/23. LPA was met by Administrator Hazzard and explained the purpose of the visit.

Records Review:

LPA reviewed six (6) staff personnel files, four (4) resident files, and conducted two (2) staff interviews. LPA Ramirez did not observe emergency disaster plan, emergency water or food supply, and proof of emergency drills being conducted every six months.

Deficiencies were cited during file review. Exit interview was held with Licensee Hazzard. 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: 07/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2023
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 3
Document Has Been Signed on 07/08/2023 03:02 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/08/2023 at 12:50 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: 07/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1565(a)(1)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, LPA Ramirez did not observe evacuation procedures, emergency and disaster plan, 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: 07/09/2023
Plan of Correction
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Licensee will provide plan to address facility emergency and disaster plan by 7/9/23. Licensee will submit final plans via email to LPA Ramirez by 7/15/23.
Type A
Section Cited
HSC
1565(a)(2)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA Ramirez did not observe emergency water and emergency lighting, or plans on how the facility would be self-reliant, 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: 07/09/2023
Plan of Correction
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Licensee will develop plan to address emergency water, emergency lighitng and how the facility plan to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. Final plan must be submitted to LPA Ramirez by 7/15/23.
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: 07/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/08/2023 03:02 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/08/2023 at 12:50 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: 07/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80023(d)
Disaster & Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee has not been conducting or record keeping of drills,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: 07/09/2023
Plan of Correction
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Licensee will develop plan to address future drills and include the first day drills will start, how staff will be trained, provide copy of training material and who will provide training. Licensee will maintain disaster log and record date, time, names of staff that participated during drill and type of drills conducted. Final plan must be submitted via email by 7/15/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2023


LIC809 (FAS) - (06/04)
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