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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603295
Report Date: 12/27/2024
Date Signed: 12/27/2024 03:20:23 PM

Document Has Been Signed on 12/27/2024 03:20 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:
12/27/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:32 AM
MET WITH:Estefany Lopez - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:53 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management-Annual Continuation visit for the required 1-year inspection. The initial visit was conducted on 12/20/2024, no deficiencies cited at the time. LPA met with Jose Hernandez, Cook and explained the purpose of the visit. Administrator, Estefany Lopez arrived shortly after and assisted LPA with the inspection. LPA continued to utilize the Compliance and Regulatory Enforcement (CARE) tools and observed the following:
Physical Plant & Environment Safety: The facility consists of (5) buildings, the main building and (4) single story cottages (E1-E4). There are two levels in the main building and has (7) bedrooms in the lower level, (21) bedrooms in the upper level, bathrooms for men & women, dining room, kitchen, living room with a fireplace, office/medication room and a laundry room. E1 consists of (6) bedrooms and (2) bathrooms, E2 consists of (4) bedrooms and (2) bathrooms, E3 consists of (4) bedrooms and (1) bathroom and E4 consists of (3) bedrooms and (1) bathroom. Random client bedrooms were toured in the main building and the (4) cottages. The bedrooms in the main building has fire sprinklers, smoke detector, bed, linen, dresser, light, chair and sufficient closet space. The bedrooms in the (4) cottages have smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Smoke alarms and carbon monoxide were tested and operable. At 10am, LPA measured the hot water supply in several bathrooms and read between 106 deg F to 109.2 deg F which were within the required 105 - 120 degrees Fahrenheit. There are (2) laundry areas in the facility with sufficient amount of washers and dryers. At 10:10am, LPA observed that the door in the laundry room where they store disinfectants, laundry soaps and other cleaning solutions was left unlocked and ajar. LPA observed that the fireplace in the living room was not properly screened and covered. Kitchen was inspected, knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. LPA observed that one of the freezers in the kitchen was dirty and has rust on the bottom shelf. LPA also observed that the trash cans/bins in the kitchen and bathrooms did not have covers. There are no firearms or weapons stored at the facility. Exit doors are free of any obstruction and there are no pools or large bodies of water. Facility provides a shaded area and sitting area for the clients. The facility has a video camera monitor system in all common areas and hallways. The facility has a total of 2 elevators, one in each building and were operational. Fire alarms, carbon monoxide detectors and the signalling systems are interconnected and notify the fire department when triggered. Toxins and sharps locked and inaccessible to residents. Fire extinguishers were observed to be fully charged and inspected on 10/11/2024.
*****CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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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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: 12/27/2024
NARRATIVE
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Staffing: A total of (18) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Administrator's certificate is valid and expires on 01/24/2026. Administrator has valid HIV/AIDS Training certificate.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed (5) staff files including the Administrator. Proof of staff training, health clearance, and vaccinations are current.
Client Rights-Information: Client personal rights are posted. Facility provides internet service and phone to the clients.
Client Records-Incident Reports: LPA reviewed (8) client files. Client files are maintained at the facility. Admission Agreement, Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Food Service: There is sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. The food is properly stored in the refrigerator. There is (1) client with special diet residing at this facility. LPA observed lack of food sanitation practices in the kitchen and the Cook did not have a valid food handling training certificate on file.
Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for (10) clients. The facility uses Medication Administration Record (MAR) to document medications given. Medications are administered as prescribed by the Physician.
Incidental Medical Services: The facility cares for some clients who have restricted health conditions. Staff are trained to assist clients with restricted health conditions and documented in the facility personnel files.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. LPA observed that there are no evacuation chairs for the (2) stairwell exits located in the main building.
Emergency Intervention: Not-Applicable.

Deficiencies cited, Technical Assistance and Technical Violation issued. Exit interview, appeals rights 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: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 12/27/2024 03:20 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/27/2024 at 01:07 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: 12/27/2024

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 Administrator did not comply with the section cited above in that at 10:10am, the door in the laundry room where they store disinfectants, laundry soaps and other cleaning solutions was left unlocked and ajar which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 12/28/2024
Plan of Correction
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Administrator shall ensure that staff responsible in the laundry area keeps the entry/exit points secured. During the visit, Administrator immediately closed/locked the door. *****DEFICIENCY CLEARED DURING THE VISIT.*****
Type A
Section Cited
CCR
80075(g)
Health-Related Services
(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator did not comply with the section cited above in that the facility did not have a valid first aid kit/supplies which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 12/28/2024
Plan of Correction
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Administrator shall ensure that a current first aid supplies kit has been purchased and readily available in the facility. Administrator will send proof such as receipts and photos to LPA/CCL 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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 12/27/2024 03:20 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/27/2024 at 01:07 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: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(c)
Fixtures, Furniture, Equipment, and Supplies
(c) Fireplaces and open-faced heaters shall be inaccessible to clients to ensure protection of the clients' safety.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the Administrator did not comply with the section cited above in that the fireplace in the living room was not properly screened and covered which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 01/03/2025
Plan of Correction
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Administrator will send proof that the fireplace has been properly secured and send photos to CCL/LPA 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, interview, the Administrator did not comply with the section cited above in that there are no evacuation chairs for the (2) stairwell exits located in the main building which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 01/03/2025
Plan of Correction
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Licensee will purchase evacuation chairs for the 2 stairwell exits located and have them installed by the POC due date. Licensee will also conduct an in-service training with staff on how to use the evacuation chairs in the event of an emergency. Administrator will send training logs, purchase receipts and photos to CCL/LPA 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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
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