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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603295
Report Date: 10/31/2025
Date Signed: 10/31/2025 04:06:39 PM

Document Has Been Signed on 10/31/2025 04:06 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
MONTEREY PARK ASC, 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: 86DATE:
10/31/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:34 AM
MET WITH:Estefany Lopez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted the required annual inspection. LPA met with Estefany Lopez, Administrator and LPA 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 an Infection Control Plan in place. Common area surfaces are being cleaned and disinfected on a regular basis. Staff are adhering to infection control requirements.

Operational Requirements: Fire clearance is in place. Valid Surety bond is in place. Valid liability insurance is in place. Last fire drill was conducted on 09/10/2025. LPA observed a furnished and shaded area in the outdoor activity area.

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, (15) 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 (2) bathrooms. LPA inspected 12 clients' rooms in the main building and the (4) cottages and each client bedroom has the required furniture such as bed frames, dressers, lamps, nightstand, and chairs. Bedrooms also have sufficient closet space. Clients’ beds have the required linen, and the linen is in good condition. Extra clean linens, pillows, and towels were observed in the basement of the main building.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASA ALTA MANOR
FACILITY NUMBER: 198603295
VISIT DATE: 10/31/2025
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Physical Plant & Environment Safety [Cont.]: The bathrooms contain a working toilet, basin, and water faucet, walk in shower and bathtub with grab bar, and skid mats. LPA measured the hot water supply in eight (8) bathrooms and read between 105.0 deg F to 118.5 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. LPA observed that the fireplace in the living room is covered and inaccessible to clients. Kitchen was inspected, knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. 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 two 2 elevators, one in each building and were operational. Carbon Monoxide Detector were tested and working properly. LPA observed Fire Alarms and a signal system in the facility. Toxins and cleaning supplies are locked and inaccessible to clients. Fire extinguishers were observed to be fully charged and inspected on 09/26/2025.

Staffing: A total of (14) 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 are associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed five (5) staff files that included Personnel Record, Employee Rights, Health Screening, TB clearance, staff training, and medication management staff training. Administrator Certificate Expires on 01/24/2026. LPA observed the Administrator has valid HIV and TB training in file.

Client Rights-Information: There are no clients with Postural Supports. Client personal rights are posted. Facility provides internet service and phone to the clients.

Client Records-Incident Reports: LPA reviewed eight (8) client files that included the Face sheet, Identification and Emergency Information, Functional Capability Assessment, Admission Agreement, Physician's Report (including TB and Ambulatory Status), Appraisal/Needs and Services Plan, Client Personal Property, and Clients Personal Rights.

Food Service: Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. 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 are no clients with a modified diet.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASA ALTA MANOR
FACILITY NUMBER: 198603295
VISIT DATE: 10/31/2025
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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. There were no issues.

Incidental Medical Services: The facility cares for one (1) client with a restricted health condition. 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 Plan. LPA observed that there are five evacuation chairs mounted nearby the Second-floor stairwell exits.

Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview and a copy of this report were provided to the Administrator, Estefany Lopez.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC809 (FAS) - (06/04)
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