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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603295
Report Date: 12/20/2024
Date Signed: 12/20/2024 08:07:32 PM

Document Has Been Signed on 12/20/2024 08:07 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/
DIRECTOR:		CHERTOK, VLADIMIRFACILITY TYPE:
735
ADDRESS:1790 N FAIR OAKS AVENUETELEPHONE:
(626) 798-6986
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 90CENSUS: 83DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Estefany Lopez - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspection. LPA met with Estefany Lopez, Administrator and explained the purpose of the visit. The facility is licensed to serve 90 ambulatory only adults ages 18 through 59. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan and was reviewed. Common area surfaces are being cleaned and disinfected on a regular basis. Staff are adhering to infection control requirements.

Operational Requirements: A current Plan of Operation was reviewed. Facility conducts fire and earthquake drills, last fire drill was conducted on 11/14/2024. Surety bond in the amount of $3000 is in place. Special equipment and supplies to meet the persons with special needs were observed. LPA observed a furnished and shaded area in the outdoor activity area.

Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will return for the continuation of this inspection. No deficiencies cited today.

Exit interview conducted and a copy of this report was provided to Administrator Estefany Lopez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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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