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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603295
Report Date: 01/25/2022
Date Signed: 01/25/2022 05:12:37 PM

Document Has Been Signed on 01/25/2022 05:12 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:PASA ALTA MANORFACILITY NUMBER:
198603295
ADMINISTRATOR:CHERTOK, VLADIMIRFACILITY TYPE:
735
ADDRESS:1790 N FAIR OAKS AVENUETELEPHONE:
(626) 798-6986
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 90CENSUS: 85DATE:
01/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Tricia PedrozaTIME COMPLETED:
05:25 PM
NARRATIVE
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1/25/2022 Licensing Program Analyst (LPA) Nina Galarza conducted an announced required annual inspection. LPA met with Administrator Tricia Pedroza and stated the purpose of the visit. LPA conducted annual inspection using the Infection Control Domain Tool. The facility is licensed for adults between the ages of 18-59 years of age who are Developmentally Disabled/Mentally Disabled for a capacity of 90 Ambulatory clients only.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility consists of 5 buildings, the main building and 4 cottages. There are two levels in the main building, 4 single story cottages and covered patio area on the grounds. The main structure has 23 bedrooms, men's and women's bathrooms on lower and upper levels, a dining room, kitchen, living room, office and a laundry room. E1 consist of 6 bedrooms and one bathroom, E2 consists of 4 bedrooms and one bathroom, E3 consists of 4 bedrooms and one bathroom and E4 consists of 3 bedrooms and one bathroom.

LPA observed a fully equipped living room and a dining room with sufficient dining capacity. The kitchen was observed for the ability to prepare and serve food. Appliances in the kitchen were clean and all appeared functional. The supply of dishes/cups are adequate. Ample supply of perishable and nonperishable foods were observed. The client bedrooms were inspected for linens and personal accommodations for safety, privacy, and comfort. LPA observed COVID informational signs throughout the facility.

Medications along with the First Aid Kit are centrally stored and locked in the medication room (located in the main building). Client and staff records are centrally stored and locked in the cabinet located in the office along with client cash resources. No firearms will be kept at the facility.
CONTINUED 809-C
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASA ALTA MANOR
FACILITY NUMBER: 198603295
VISIT DATE: 01/25/2022
NARRATIVE
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 The facility is equipped with a smoke alarm/sprinkler system. The fire extinguishers were observed to be operational. There is a functioning telephone on the premises. All toxins such as cleaning solutions and detergent soap are kept locked and inaccessible to clients. Sharps are also kept locked and inaccessible to clients. LPA reviewed client medications records and stored medication. All medications were properly labeled and administered as directed by the physician.

There was no pool or bodies of standing water observed in the exterior of the facility property. Exits and passageways were free of obstructions.

The following deficiencies were observed during today's visit:

  • Water temperature of 92.7 degrees Fahrenheit in shared bathroom of E2 cottage
  • Window in shared bathroom of E2 cottage with a missing window
  • Water temperature of 93.3 degrees Fahrenheit in shared bathroom of E1 cottage
  • Water temperature of 127.7 in room 27 of the main building

Deficiencies cited, refer to 809-D



Exit interview held, copy of report and appeal rights provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/25/2022 05:12 PM - It Cannot Be Edited


Created By: Nina Galarza On 01/25/2022 at 04:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PASA ALTA MANOR
FACILITY NUMBER: 198603295

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, Equipment, and Supplies (e)Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.(1)Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed water temperature of 93.3 degrees Fahrenheit in shared bathroom of E1 cottage, water temperature of 127.7 in room 27 of the main building and water temperature of 92.7 degrees Fahrenheit in shared bathroom of E2 cottage. Based on observation, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2022
Plan of Correction
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Administrator will provide water temperature log of all buildings to LPA by POC date
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nina Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/25/2022 05:12 PM - It Cannot Be Edited


Created By: Nina Galarza On 01/25/2022 at 05:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PASA ALTA MANOR
FACILITY NUMBER: 198603295

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds (a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Window in shared bathroom of E2 cottage with a missing window. Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2022
Plan of Correction
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Administrator will provide picture proof of window repaired via email to LPA by POC date.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nina Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2022


LIC809 (FAS) - (06/04)
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