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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602896
Report Date: 09/26/2023
Date Signed: 09/26/2023 10:50:36 AM

Document Has Been Signed on 09/26/2023 10:50 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: 24DATE:
09/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Carolee HazzardTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit on 9/26/23 at 9 am. LPA Ramirez gained entry into the facility at 9:03 am. LPA Ramirez was greeted by clients upon entry. LPA Ramirez conducted facility tour while Administrator/Licensee Carolee Hazzard prepared breakfast for clients in care.

Case Management- findings:

ยท LPA Ramirez toured facility and observed three (3) bathrooms on 1st floor to contain Master padlocks. Per Administrator/Carolee Hazzard, these bathrooms are under remodel and pose a potential hazard to clients in care if they are left accessible to clients in care. LPA Ramirez observed four (4) additional full bathrooms, of which, one (1) was located on the 1st floor of the facility and three (3) located on the 2nd floor. The 2nd floor bathrooms appeared to have been recently remodeled.

Licensee will develop a plan to address the additional remodeling to downstairs bathrooms and provide a time frame by 10/01/23. All remodeling in downstairs bathrooms should bed completed by 10/31/2023. Licensee will send pictures of completed downstairs bathrooms by 10/31/23.



No deficiencies are being cited however, LPA issued Technical Violation. Exit interview was conducted. A copy of this report, LIC 9102, and appeals rights was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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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