198603270-1-16-2025-28-AS-MGFS-DCYUW8-20250116145618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603270
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:56:26 PM

Document Has Been Signed on 01/16/2025 02:56 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:	GRANT SERENITY HOMES OF PASADENA, INC.		FACILITY NUMBER:	198603270
ADMINISTRATOR/ DIRECTOR:	NORAYR BADALYAN		FACILITY TYPE:	740
ADDRESS:	1745 WAGNER STREET		TELEPHONE:	(818) 425-6797
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	01/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	David Fontecha - Caregiver		TIME VISIT/ INSPECTION COMPLETED:	03:15 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)s Mary Flores and Nicol Wesley conducted an unannounced annual visit at the facility using the CARE inspection tool. LPAs met with David Fontecha and explained the reason of the visit. 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. LPAs conducted a tour of the facility with Juan Fontecha and observed the following: Facility is in good repair inside and outside. Living and dining area are clean and have sufficient sitting area for activities. Kitchen is clean, food was observed sufficient for at least 2 days of perishables and 7 days of non-perishables. Current residents do not have special diets. Sharps were observed locked on a drawer and cleaning supplies were observed locked under the sink. Six (6) resident's rooms were observed and each has sufficient lighting, furniture, and bedding supplies. Bedroom #1 has a covered fireplace. Full bed rails were observed in bedroom #4. Bathroom was observed with skid mat, grab bars and water temperature was tested at 118.5 degrees F., which is within the required 105-120 degrees F. Garage is used for storage of emergency food supplies and infection control supplies. The backyard was observed clean and has a shaded seating area. Due to the winds backyard fence was knocked down and observed on the floor. Administrator will ensure that is clean up by 1/20/25. Interlace smoke/carbon monoxide detectors were tested during the visit and in working condition. Fire extinguishers were observed and last checked on 10/8/24. There are no large bodies of water at the facility. License, PUB 475 Let us Know poster, Long Term Care Ombudsman poster, personal rights were posted in the dining area. (CONTINUED ON LIC 809C)

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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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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: GRANT SERENITY HOMES OF PASADENA, INC.	FACILITY NUMBER: 198603270
	VISIT DATE: 01/16/2025

NARRATIVE

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LPAs reviewed medication and files for 5 residents. Resident #2(R2) in bedroom #4 has half bed rail request on file and per file review is not on hospice. LPAs reviewed 5 staff files. Training was observed for all residents.

Administrator certificate was observed for Diana Castellanos #6073850740 exp. date: 1/6/27.

LPAs reviewed infection control plan and disaster emergency plan. Last fire drill was conducted on 11/6/24.

A deficiency has been noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Mariam Nikogsyan and provided a copy of report, LIC 809D, and appeal rights.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/16/2025 02:56 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
GREATER LA AC/SC, 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: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance...supports may be used under the following conditions. (5) Under no circumstances shall postural supports ... (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 6 residents, R2's bed was observed with full bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/23/2025
	Plan of Correction
1 2 3 4	Administrator will either switch full bed rails from full bed rails to half bed rails per the physician's half bed rail request or will communicate with family and physician to evaluate the need for hospice care and will submit to the department either pictures of the bed with half bed rails or hospice plan with the full bed rail request to the department by POC due date 1/23/25.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC809 (FAS) - (06/04)

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