198603384-5-2-2024-28-AS-FFIS-D5BQ2G-20240516114704

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603384
Report Date: 05/02/2024
Date Signed: 05/02/2024 03:00:33 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/25/2024 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240425201839

FACILITY NAME:	PASADENA HIGHLANDS		FACILITY NUMBER:	198603384
ADMINISTRATOR:	KAY CANO		FACILITY TYPE:	740
ADDRESS:	1575 E WASHINGTON BLVD		TELEPHONE:	(801) 815-0808
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	245	CENSUS: 188	DATE:	05/02/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Kay Cano		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff do not keep the facility free from rodents
Staff do not properly sanitize kitchen items
Staff do not keep the facility free from mildew
Staff do not follow proper food handling techniques

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced initial complaint investigation visit for the allegation listed above. LPA Villalobos met with Administrator Kay Cano and the purpose of the visit was discussed.

LPA conducted the following on todays visit: LPA collected a copy of the staff and resident roster, LPA Interviewed Staff #1-#8 (S1-S8) and Residents #1-#10 (R1-R10), LPA toured the physcial plant including the outside gardens and along the walls, LPA inspected the facilities food supply and kitchen area, LPA reviewed documentation of pest control services contracted by the facility for the last month, and reviewed work orders requested by facility residents for the last month. The investigation revealed the following:

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240425201839

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PASADENA HIGHLANDS	FACILITY NUMBER: 198603384
	VISIT DATE: 05/02/2024

NARRATIVE

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In regards to the allegation "Staff do not keep the facility free from rodents" it was alleged that the facility dining area has rodents. (8) of (8) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegations. Interviews with residents did not show that they are aware of or have seen any rodents in the facility. No residents has heard of or seen rodents in the dining area. (2) of (8) Staff interviewed did mention that sometime in 2023 there were rodents observed by staff near the back entrances of the kitchen but not in the dining area. Staff interviewed stated they are aware pest control will always be contacted to address the issues once reported. Staff informed LPA that pest control visits the facility almost twice a week. LPA observed that there were a total of (7) visits conducted in April 2024 of routine maintenance and inspections. Review of pest control notes for the last month do not show that rodents have been observed in the kitchen or dining area. One note dated 4/26/24 from the pest control agency does mention that there were rodent dropping observed in the air ducts and pipes; therefore, mass trapping measures were recommended. It does not mention which air ducts and pipes; however, the facility agreed to the recommended measure as of 4/30/24. This shows the facility is following through measures to keep the facility free of pests and rodents. Based on interviews, observations and files reviewed; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

In regards to the allegation "Staff do not properly sanitize kitchen items " it is alleged that water pitchers and utensils are not being cleaned properly by staff. (8) of (8) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegations. Interviews with residents denied that they have ever been served dirty dishes or utensils. Staff interviewed explained the process of washing and sanitizing all kitchen and dining utensils requires a prewash before using a sanitization machine for all items. LPA observed kitchen staff washing utensils then sanitizing them via various machines during the visit. LPA did not observe residents being provided unsanitary utensils during the facilities lunch time. Based on interviews, observations and files reviewed; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240425201839

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PASADENA HIGHLANDS	FACILITY NUMBER: 198603384
	VISIT DATE: 05/02/2024

NARRATIVE

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In regards to the allegation "Staff do not keep the facility free from mildew" it is alleged that staff are not cleaning mildew around the facility sinks. (8) of (8) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegations. Staff interviewed stated the kitchen sinks are always cleans after all utensils are done being cleaned. If there is any sign of mildew build up, the staff will clean and disinfect. LPA toured the kitchen area and did not observe mildew around the sinks. LPA entered (6) random resident rooms and did not observe any mildew. File review of maintenance and order requests from residents of the facility does not show that residents are having to call in for assistance regarding mildew. Based on interviews, observations and files reviewed; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

In regards to the allegation "Staff do not follow proper food handling techniques " it is alleged that the facility has expired sauces, milk, and food in their refrigerators. (8) of (8) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegations. LPA Villalobos observed the facilities food supply and did not see any expired sauces, milk, or food present. LPA did not observe any canned foods to be expired either. Staff stated that expiration dates are written in large letters on all boxes so it is easier to distinguish when something is going to expire. The facility Chefs make rounds throughout the week to observe if anything needs to be disposed of as replaced as new food is brought in two times a week. Based on interviews, observations and files reviewed; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit Interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC9099 (FAS) - (06/04)

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