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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602896
Report Date: 05/19/2025
Date Signed: 05/19/2025 03:08:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/16/2025 and conducted by Evaluator Luis DeLeon
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250516130106
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: 26DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator Carolee HazzardTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff are making clients work as facility staff members
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Luis De Leon and Licensing Program Manager (LPM) Fernando Fierros conducted an unannounced initial complaint investigation visit for the allegation listed above. LPA met with the Administrator Carolee Hazzard and explained the reason for the visit.

The investigation consisted of the following: On today’s visit, LPA De Leon toured the physical plant with caregiver Star Hodges, revised six client files and obtained pertinent documents from client #1 (C1's) facility file, including C1's Admission Agreements, Psyche Assessment and Appraisal Needs and Services plan dated 03/25/2016, staff’s Personal Rights training conducted on 10/22/23. LPA DeLeon obtained a copy of a current staff roster. LPA interviewed six (6) out of twenty-six (26) clients and two (2) out of (4) staffs
Substantiated
Estimated Days of Completion: 90
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20250516130106
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/19/2025
NARRATIVE
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Regarding allegation: Staff are making clients work as facility staff members. It is alleged that staff are are instructing facility clients to assist in performing task that would be assigned to staff. During clients’ interview, six (6) out six (6) clients revealed that no clients were asked by staff to perform work for the facility. Interviews with clients confirmed that clients perform chores at facility, but staff do not requests for the work to be done by the clients. Clients offer to do house chores to help out and to stay busy. Interviews with two (2) out of two (2) staff revealed that staff do not asks client's to perform work at facility. Interview with Administrator revealed that an incident where a mental health agency visited the facility, Administrator asked a client to tour the facility with the agency about two months ago. Administrator stated that it occurred only that one time. LPA observed a client preparing coffee to share with other clients, however, staff did not instruct the client to prepare or serve coffee to other clients. LPA observed a client running errand to market, however, staff did not ask the client to go run errands at the market. The investigation revealed of one instance where staff asked a client to perform a task that is a staff duty which was not part of the client's needs and services plan.

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 1, are being cited on the attached LIC 9099D.

Exit interview was held with Administrator Carolee Hazzard. A copy of the report LIC-9099, LIC-9099C, LIC-9009D and appeal rights were provided and discussed.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250516130106
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2025
Section Cited
CCR
80065(j)(1)
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Personnel Requirements (j) Clients shall not be used as substitutes for required staff but shall be permitted, as a voluntary part of their program of activities, to participate in household duties and other tasks suited to the client's needs and abilities. (1) Such duties and tasks shall be specified in the client's needs and services plan...

This requirement is not met as evidenced by
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Licensee will read section of regulation and provide CCLD with a letter by POC due date 5/26/2025 stating that Licensee will comply with the cited regulation.
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Based on interviews, the licensee did not comply with the section cited above, staff requested a client assist with a facility tour when a third party agency visited the faccilty, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3