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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603295
Report Date: 07/06/2023
Date Signed: 07/06/2023 03:37:18 PM

Document Has Been Signed on 07/06/2023 03:37 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: DATE:
07/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Assistant Adminsitrator- Estefany LopezTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced case management visit regrading a death of a client who resided at the above facility. LPA discussed the purpose of todays visit with Assistant Administrator Estefany Lopez. On 6/23/23, LPA Calderon received Death Report from the above facility. Regarding client #1 (C1's) death.

On 6/22/23 based on Special Incident Report C1's roommate witnessed C1 stumble and clutching chest and fell to the ground. Roommate informed staff. Staff called 911, when 911 arrived C1 was transported via ambulance to Huntington Hospital Emergency Room for further assistance. Client passed away when admitting to the hospital. Per Huntington Hospital cause of death was said to be: Cardiac Arrest. Client passed away on 6/22/23 at the Hospital at 9:30pm. Client was self responsible. Assisted Living Wavier Program notified as well as client’s mother and sister were informed about incident leading to death. No recent hospitalization's stated on Death Report provided to Licensing. Death Report submitted to licensing.

On 6/23/23 LPA Calderon reviewed and received : Client’s Physician Report dated 3/10/23, Face Sheet, Pre Placement Appraisal , Functional Capability Assessment and Latest Medication Records (MARS) for June/July.



On todays visit 7/6/23 LPA Calderon requested: staff and resident roster, C1 Shift Report, Current Appraisal / Needs and Service Form, medication log for April / May 2023, and Medical Records . LPA alongside with Lopez toured facility. Facility has 1 main building and 4 cottages, common areas: outside patio spaces, dining/ activity room, tv room, north wing activity room, main activity room and kitchen. Sufficient perishable and non-perishable food items were observed for clients in care. LPA toured C1's room, rooms # 2,3,27,35,38,41 and 45. Continuation 809-C...
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASA ALTA MANOR
FACILITY NUMBER: 198603295
VISIT DATE: 07/06/2023
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Lopez stated family took C1's personal belongings on 6/30/23 and facility was not responsible for C1's P&I's. C1's medications are destroyed, medication by two staff members were counted and logged and place them in a sealed container and then a company picks up and disposes medications.

During the tour: No health and safety concerns, obstructions, or anything out of the ordinary was witnessed during the visit.

LPA requested facility to obtain and provide Licensing with C1's Death Certificate. Lopez stated family member has not received one yet but will provide one to facility for records. Lopez will provide caseload LPA with certificate once received.

No deficiencies observed during today's visit. Exit interview held and a copy of the report was provided to the facility.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
LIC809 (FAS) - (06/04)
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