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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603270
Report Date: 12/02/2023
Date Signed: 12/02/2023 02:53:52 PM


Document Has Been Signed on 12/02/2023 02:53 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:GEVORKIAN, NVARDFACILITY TYPE:
740
ADDRESS:1745 WAGNER STREETTELEPHONE:
(818) 425-6797
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:6CENSUS: 5DATE:
12/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Hakob Gevorkyan - CaregiverTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Hakob Gevorkyan and explained the reason for 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.

LPA Flores conducted a tour of the facility with Hakob Gevorkyan 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. Sharps were observed locked on a drawer and cleaning supplies were observed locked under the sink. Resident's rooms (6) were check and each has sufficient lighting, furniture, and bedding supplies. Bedroom #1 has a covered fireplace. Bathroom was observed with skid mat, grab bars and water temperature was tested at 86.3 degrees F., which is not 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. Interlace smoke/carbon monoxide detectors were tested during the visit and in working condition. LPA did not observed PUB745 - Let us know poster posted at the facility. Fire extinguishers were observed and last checked on 10/19/23.

LPA reviewed medication and files for 5 residents. Resident #4(R4)'s medication was observed without prescription labels and out of the original container. Resident #3(R3) did not have a pre-appraisal on file. LPA reviewed 5 staff files and no record of initial or annual training was observed in files for staff #2-5(S2-S5).

LPA reviewed infection control plan which was last reviewed on 7/1/22 and disaster emergency plan which was last reviewed on 6/1/21. Last fire drill was conducted on 10/1/23. (CONTINUED ON LIC 809C)
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2023
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: 12/02/2023
NARRATIVE
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Administrator certificate was posted for Nvard Gevorkian#6050643740 and exp. on 12/23/24. No record of designee letter was observed and facility has assigned staff #4 and #5 as the designee staff.

LPA interviewed 2 staff and 2 residents.

Deficiencies were noted during this visit on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Nvard Gervokian administrator and a copy of this report, LIC 809D, technical violations, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2023 02:53 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: 12/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(4)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:
(4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

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 medication for R4 was observed without a prescription label which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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Administrator will contact the pharmacy and obtain medication for R4 with prescription label and discard of the medication without a label. Administrator will provide a picture of new medication to the department by POC due date 12/4/23.
Type A
Section Cited
CCR
87465(h)(5)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 medication for R4 does not have the original container which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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Administrator will contact the pharmacy and obtain medication for R4 with prescription label and original container and discard of the medication without a label. Administrator will provide a picture of new medication to the department by POC due date 12/4/23.
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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2023
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 12/02/2023 02:53 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: 12/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation(e) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree 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 water temperature in bathroom was tested at 86.3 degrees F., which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Administrator adjusted temperature to the required 105-120 degrees F., and will maintained a water temperature log for the next seven days and will submit the log to the department by POC due date 12/8/23.
Type B
Section Cited
CCR
87456(a)(2)
87456 Evaluation of Suitability for Admission (a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

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 R3 does not have a pre-admission appraisal on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Administrator will create the pre-admission appraisal for R3 and will submit a copy to the department by POC due date 12/8/23.
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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2023
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 12/02/2023 02:53 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: 12/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
87468 Personal Rights (c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or...

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 Poster (PUB 745) was not posted in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Administrator will obtain and post PUB 745 and will submit a picture to the department by POC due date 12/8/23.
Type B
Section Cited
HSC
1569.625(b)(1)
1569.625 Staff training; legislative findings; contents
(b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training.

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 4 out of 5 staff files review did not have initial training provided for S2-S5 for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Administrator will submit a copy of initial 40 hours of training provided to S2-S5 either by signing logs that include a topic, duration of training, and signatures or certificates to the department by POC due date 12/8/23.
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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2023
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 12/02/2023 02:53 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: 12/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
1569.625 Staff training; legislative findings; contents
(b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 4 out of 5 staff files reviewed did not have 20 hours of annual training for S2-S5 to review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Administrator will provide copies of 20 hours of annual training by signing logs with training topic, duration of training, or certificates for S2-S5 to the department by POC due date 12/8/23.
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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2023
LIC809 (FAS) - (06/04)
Page: 6 of 9