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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603270
Report Date: 11/29/2022
Date Signed: 11/29/2022 12:42:08 PM


Document Has Been Signed on 11/29/2022 12:42 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:GRANT SERENITY HOMES OF PASADENA, INC.FACILITY NUMBER:
198603270
ADMINISTRATOR:GEVORKIAN, NVARDFACILITY TYPE:
740
ADDRESS:1745 WAGNER STREETTELEPHONE:
(818) 425-6797
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:6CENSUS: 6DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Melanya Khachatryan - Caregiver TIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst(s) Mary Flores conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Flores met with Melanya Khachatryan Caregiver and explained the reason for the visit. Administrator Nvard Gevorkian arrived 40 minutes later.

The facility is licensed to served 6 non-ambulatory residents age range 60 and over, of which 1 may be bedridden and hospice waiver for 6. The facility has 6 bedrooms, 1 bathroom, a dining room, a living room, a detached garage, a detached laundry room, back patio and a front yard. Facility has interlace smoke/carbon monoxide detectors that were tested during the visit and in working condition.

LPA Flores conducted the tour with Melanya Khachatryan Caregiver and observed the following:
Upon arrival LPA observed caregiver and hospice nurse without a face mask while providing care to the residents. LPA signed into visitors log, no screening was conducted by caregiver. LPA inquired the steps conducted with visitors and no signs of screening visitors were mentioned. Six residents rooms were observed to have sufficient lighting, bedding, and required furniture. Full bed rails were observed in room #2(BR2) and #6(BR6), and half bed rails were observed in room #3(BR3) and #5(BR5). Dining area and living room were observed with proper furniture and lighting. Fire extinguishers were observed outside kitchen door and in exit door to driveway located in the kitchen. Facility has sufficient food for at least 2 days worth of perishables and 7 days of non-perishables. Cleaning supplies were locked under cabinet sink and sharps were locked in drawer next to the sink. Bathroom was observed to have grab bars and skid mat and water temperature was tested at 114.6 degrees F which is within the required 105-120 degrees F. LPA reviewed medication for 3 residents, files for 5 residents, no physician's orders were observed in files for half bed rails for resident #3(R3), and #4(R4), files for 3 staff were reviewed. Administrator certificate #6050643740 exp: 12/23/22 for Nvard Gevorkian. Signs were observed in bathrooms, main entrance, and front entrance. A shaded sitting area was observed outside. The facility is clean and in good repair.
Deficiency is noted on LIC 809D. Exit interview was conducted with Nvard Gevorkian Administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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 6


Document Has Been Signed on 11/29/2022 12:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: GRANT SERENITY HOMES OF PASADENA, INC.
FACILITY NUMBER: 198603270

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

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 2 out of 6 residents were observed to have half bed rails in their beds for R3 and R4 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2022
Plan of Correction
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Administrator is to obtained a physician's order for the half bed rails or remove half bed rails and submit a copy of the physician's request or pictures to the department by 11/30/22.
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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
LIC809 (FAS) - (06/04)
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