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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603295
Report Date: 10/31/2023
Date Signed: 10/31/2023 03:49:09 PM

Document Has Been Signed on 10/31/2023 03:49 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: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: 87DATE:
10/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Estefany Lopez - AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Tricia Pedroza (Owner) and Estefany Lopez (Administrator) and explained the purpose of today’s visit. The facility is licensed to serve 90 Ambulatory only adults ages 18 through 59.

The facility is located in Pasadena, CA. A tour of the facility includes: a total of 49 rooms and 20 bathrooms, there are 5 buildings, the main building and 4 cottages. There are two levels in the main building, 4 single story cottages (E1-E4) 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 with pantry and walk-in fridge, tv/living room, activity room, office, medication room and a laundry room. North-Wing consists of 4 down stairs rooms and 5 upstairs rooms, and bathrooms, 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 4 bedrooms and one bathroom.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.


Physical Plant & Environment Safety: Smoke detectors and carbon monoxide detectors are operable and in compliance. Bathrooms are clean and operational, LPA did observe shower in Unit E3 was observed to have a leak, details will be cited on the 809-D page. 12 clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises.
(Continued on 809-D)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2023
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 10/31/2023 03:49 PM - It Cannot Be Edited


Created By: Tena Herrera On 10/31/2023 at 03:09 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: 10/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 as during tour cleaning soultion was observed in an unlocked cabinet within client restroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2023
Plan of Correction
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**Administrator immediatly removed disinfectant/cleaning solution and stored in a secured locked location during visit**
Administrator to conduct an in-house training with staff to ensure that there is no cleaning supplies left unattened and unlocked during rounds. Training materials and Training Log to be submitted to LPA via email by 11/14/23.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, 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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Based on observation, the licensee did not comply with the section cited above as LPA tested water throughout facility and temperature reached 126.6 degrees F in the NorthWing area, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2023
Plan of Correction
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**Administrator had staff lower water temperature during visit**
Administrator to create a water temperature log and test water temperature throughout the facility 3x a day for the next 5 days and submit log to LPA via email by 11/07/23.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 10/31/2023 03:49 PM - It Cannot Be Edited


Created By: Tena Herrera On 10/31/2023 at 03:09 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: 10/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

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 as 1 out of 10 Clients medications reviewed LPA observed a client missed 2 am medications, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2023
Plan of Correction
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**Administrator to send incident report documenting all protocalls done during todays visit after medication was observed and confirmed to be missed via email by POC due date 11/1/23**
Additionally, administrator will hold an inhouse training for staff that assist with medication and submit training log and training materials to LPA by 11/14/23.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/31/2023 03:49 PM - It Cannot Be Edited


Created By: Tena Herrera On 10/31/2023 at 03:09 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: 10/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

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 as during tour LPA observed shower head in bathroom within unit E3 to be leaking, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2023
Plan of Correction
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Administrator to have facility repair man fix shower head by end of week, administrator will submit copy of receipt of purchased item and photo of new shower head installed to LPA via email by POC due date.
Type B
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

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 as during tour LPA did not see any evacuation chairs at facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2023
Plan of Correction
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Administrator stated will purchase evacuation chairs for each stairwell to meet the required regulation and will submit copies of receipts to LPA via email by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023


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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: PASA ALTA MANOR
FACILITY NUMBER: 198603295
VISIT DATE: 10/31/2023
NARRATIVE
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Hygiene products are readily available to the clients. The hot water temperature was tested throughout the facility and LPA observed that in some units’ water measured below required range and others were above in NorthWing water temp measured at 126.6 degrees F and restroom in room 7 measured at 89.7 degrees F are not within the required range of 105-120 degrees F, details will be cited on the 809-D page. Storage areas for cleaning solutions, toxins, knives, and hazardous items were observed to be locked area inaccessible to clients, however, during tour LPA observed cleaning solutions to be stored in one of the restroom cabinets, details will be cited on the 809-D page. The fire extinguishers were observed and is fully charged. Facility has telephone service on premises. There is a sprinkler system approved by the fire marshal throughout the facility.
Operational Requirements: The facility maintains the required fire clearance and plan of operation on file. The facility ensures that clients are given the opportunity to participate in community activities and there is a shaded area that is equipped for outdoor use.
Staffing: There appears to be sufficient staffing at all times in the facility with at least one CPR trained employee on the premises at all times. Administrator Estefany Lopez certificate expires 1/23/2024.
Personnel Records-Training: Staff has criminal record clearance, current first aid and CPR, and ongoing training. Staff files are maintained at the facility and kept in locked within the office area. During today’s visit LPA observed 6 staff files with no issues.
Client Rights-Information: Facility provides clients with telephone and internet.
Client Records-Incident Reports: Client files are kept in a secure location within the staff office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA observed 8 client files during today’s visit with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Services: All medications for clients are kept locked and inaccessible to other clients. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. During the visit today, LPA reviewed 10 clients’ medication 1 out of the 10 clients had a missed am dose of medication, details will be cited on the 809D page.
Incidental Medical & Dental: All training for staff who assist clients with restricted health conditions is documented in the facility personnel files and performance is reviewed annually.
(Continued on 809-D)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
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: PASA ALTA MANOR
FACILITY NUMBER: 198603295
VISIT DATE: 10/31/2023
NARRATIVE
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Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last emergency/fire drill was conducted on 10/4/2023.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

LPA conducted 5 staff interviews and 8 client interviews during today’s visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on 809D.

Exit interview was held and a copy of the report was provided Administrator Estefany Lopez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC809 (FAS) - (06/04)
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