198602896-5-9-2025-28-AS-SVAD-DGHRZN-20250509132814

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602896
Report Date: 05/08/2025
Date Signed: 05/09/2025 01:28:35 PM

Document Has Been Signed on 05/09/2025 01:28 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 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: 25	DATE:	05/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:03 AM
MET WITH:	Carolee Hazzard, Licensee		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Sanjay Vaid conducted an unannounced required 1 year visit using the Care Compliance and Regulatory Enforcement Tools. The facility is licensed to serve 30 ambulatory clients, ages 18-59. Facility fees are due in June 2025. LPA discussed with Carolee Hazzard, Administrator regarding the purpose of today's visit and the inspection and was granted entrance. There are twenty-five (25) ambulatory clients currently residing within the home. Infection Control: Infection control practices were observed. Physical Plant/Environment Safety: The facility is a two-story home located within a residential neighborhood. The facility consists of seventeen (17) client bedrooms, a kitchen, a dining room, two (2) television rooms, and five (5) client bathrooms, water temperatures measured between the required 105 - 120 degrees Fahrenheit. 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 six (6) client bedrooms. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There are no pools or bodies of water at the facility. 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. 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: During visit four (4) staff were observed providing care for clients that do not go to day programs. There are five 5) full time staff. Continued on 809C....

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

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: 05/08/2025

NARRATIVE

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Personnel Records/Staff Training: Four (4) 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.
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.
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 observed provided during the visit. Fired disaster drill was last conducted in January 2025.
Emergency Intervention: No manual restraints or seclusion are used with clients in care.

LPA Vaid reminded licensee of facility balance due, licensee will send cashiers cheque to Licensing for the balance.

Exit interview held and a copy of the report were provided to Licensee, Carolee Hazzard.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

LIC809 (FAS) - (06/04)

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