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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602896
Report Date: 06/04/2024
Date Signed: 06/04/2024 03:30:32 PM

Document Has Been Signed on 06/04/2024 03:30 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/
DIRECTOR:		HAZZARD, CAROLEEFACILITY TYPE:
735
ADDRESS:1025 N. LOS ROBLES AVENUETELEPHONE:
(626) 798-0869
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 30CENSUS: 22DATE:
06/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:27 AM
MET WITH:Carol Hazard - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Carolee Hazzard, Administrator for the facility, and was granted entrance. There are twenty-two (22) ambulatory clients who reside within the home.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices were observed. LPA asked administrator to submit the facility infection control plan to LPA if it is not on file currently.



Physical Plant/Environment Safety:

· The facility is a two-story home located in a residential neighborhood that is licensed for a capacity of thirty (30) ambulatory clients between the ages of eighteen (18) through fifty-nine (59).It consists of seventeen (17) client bedrooms, a kitchen, a dining room, two (2) TV rooms, and five client bathrooms of which Restrooms #1 – 5 (R1 – R5) had hot water temperature readings of 113.1 Degrees F, 118.2 Degrees F, 71.4, 117.1 Degrees F, and Degrees F, and 117.7 Degrees F. R3’s hot water has a very low water temperature and does not produce hot water. The facility also contains a back patio area with multiple shaded areas, and a locked storage container that contains the facility’s emergency food supplies. LPA toured eight (8) client bedrooms and observed that one (1) client bedroom did not have a window screen, one (1) client bathroom’s shower is not currently operation, and one (1) client bedroom had a broken drawer. Additionally, there was a client bedroom that was missing a window screen as well.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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 7
Document Has Been Signed on 06/04/2024 03:30 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 06/04/2024 at 02:18 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: 06/04/2024

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 22 out of 22 clients, as LPA observed a broken drawer in bedroom #3, the faucet in the upstairs restroom without a shower has very low water pressure, and a separate bathroom upstairs does not have an operational shower, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
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Administrator is to ensure that the facilities fixtures are in good repair at all times. Administrator is to send LPA proof that the drawer in bedrrom #3 has been repair, that the faucet in the partial restroom has an adequate water pressure, and that the separate upstairs shower is being repaired by the POC due date.
Type B
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, the licensee did not comply with the section cited above in 22 out of 22 clients, because the bathroom which does not have a shower does not produce hot water and had a hot water temperature reading of 71.7 degrees, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2024
Plan of Correction
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Administrator is to ensure that the hot water temperature produced by faucets shall be within the required range at all times. Administrator is to keep a water log for the restroom and submit the water temperature log that the termperature is within range by the 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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 06/04/2024 03:30 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 06/04/2024 at 02:18 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: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 5 out of 5 staff, because no staff files reviewed had a current CPR/First Aid training they all expired in July of 2019, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
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Administrator is to ensure that the facility has renewed CPR/First-Aid training at all times. Administrator is to update the facility's CPR/First-Aid training for all staff members and email LPA proof that they have been renewed by the POC due date.
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 2 out of 5 clients, because there was no physician's report with a documented TB clearance, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
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Administrator is to ensure that all clients have a physician's report with a TB clearance on file in their records at all times. Administrator is to obtain the physician's report for the 2 clients and submit it to the LPA by the 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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/04/2024 03:30 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 06/04/2024 at 02:18 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: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 22 out of 22 clients, as there is no documented Emergency and Disaster Plan LIC610D on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
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Administrator is to ensure that the emergency and disaster plan is posted within the facility at all times. Administrator is to show that the disaster plan has been completed and posted within the facility at all times.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

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 22 out of 22 clients, as there was no documented disaster drill on file for the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
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Administrator is to ensure that the facility is to conduct and document and emergency and disaster drill at least once every 6 months. Administrator is to conduct a drill and submit documentation of when the drill was conducted to the LPA by the 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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 06/04/2024 03:30 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 06/04/2024 at 02:30 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: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 1 out of 22 clients, as one client's bedroom observed did not have a window screen, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
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Administrator is to ensure that window screens are placed on all window screens at all times. Administrator is to install a window screen in client bedroom #8 and submit photographic proof to LPA by the POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


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: 06/04/2024
NARRATIVE
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·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There are no pools or accessible bodies of water for the clients to access. The facility has two (2) fully charged fire extinguishers that are kept in the facility. Cleaning supplies and toxic substances are kept locked and inaccessible to clients.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.

Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for thirty (30) ambulatory clients between the ages of 18 – 59.


· Care and supervision to meet the clients’ needs was observed.
Staffing:

· A total of seven (7) full-time staff members provide care and supervision to the clients.


Personnel Records/Staff Training:

· Five (5) staff files were reviewed for criminal background clearance and training.


· Personnel records have health/Tuberculosis (TB) screenings, certifications.
· First-Aid/CPR training for all staff was observed to have expired on July of 2019.
Client Rights/Information:

· Physician orders were reviewed in client files.


Client Records/Incident Reports:

· Five (5) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and Personal and Incidental (P & I) money were reviewed.


· Two (2) out of five (5) reviewed did not contain a physician’s report with a TB clearance attached on them.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: 06/04/2024
NARRATIVE
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Food Service:

· The kitchen was inspected and the food preparation area, and storage areas were observed to be clean and sanitary. A seven (7) day supply of non-perishable food and two (2) day supply of perishable foods were observed in the kitchen.


· None of the clients of the facility have a restricted health condition or restricted health care plan.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.


· Five (5) centrally stored client medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.
Incidental Medical and Dental:

· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.



Disaster Preparedness, and Emergency Intervention:

· An Emergency Disaster Plan LIC610D was not provided during the visit.


· There was no documented disaster drill kept within the facility.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.



Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
LIC809 (FAS) - (06/04)
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