198603384-9-27-2024-28-AS-SVAD-D9HQUR-20240927122910

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603384
Report Date: 09/27/2024
Date Signed: 09/27/2024 12:29:16 PM

Document Has Been Signed on 09/27/2024 12:29 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:	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: 197	DATE:	09/27/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	08:46 AM
MET WITH:	Kay Cano , Facility Executive Director		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/27/24, Program Analyst (LPA) Vaid made an unannounced visit to the facility to conduct a Case Management visit to evaluate third floor -Memory Care, Health and Safety inspection. LPA met with Executive Director Kay Cano and explained the purpose for the visit. The Facility is an 8-floor building located in commercial /residential location. The facility has been renovated to expand housing for memory care residents from first floor to the third floor, housing memory care residents only. Dementia needs will be met on case by case basis. The facility has a new approved fire clearance LIC 850 dated 09/11/2024 and is approved for 245(two hundred fourty-five) non-ambulatory of which 30 (thirty) may be bedridden, hospice waiver for 30. There are currently 28 residents on hospice. Current request for increase to hospice population, awaiting approval. Delayed egress on the third floor and passed the inspection permit BLDMF2022-00588. Bedridden clients approved floor 3. Meet California Building Code 2022 435.5.1- smoke barriers. Three doors on the 3rd floor have the egress delay, each door at the end of hallways and on exit door by the elevators. The doors alarms will engage when attempting the push door open, 15 second delay with alarm blaring before doors open as per fire code. Conducted the 3rd floor inspection with maintenance director John Arbona, whom explained the delay egress process and tested the doors. Staff will have communication via walkie-talkies. 1st floor has a large dining room, common area, kitchen, salon, theater, fitness room, medication room, linen room, laundry room, trash room, club room, multipurpose room, billiard room, staff office, an elevator and public restrooms. The garden area has covered seating areas, walk around path and activities areas for the residents, a permanent garden is overseen by the residents. 2nd floor has lobby area 24 (twenty-four) rooms with bath, laundry room, employee break room, medication room, lobby, and staff office. CONTINUED on 809C........

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA HIGHLANDS	FACILITY NUMBER: 198603384
	VISIT DATE: 09/27/2024

NARRATIVE

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3rd floor will house the memory care residents, 1-2 residents per rooms. Dining room, activity room, laundry room. Egress alarms on three doors exiting the floor to the stairwell and each stairwell has evacuation chairs. The appliances in the memory care rooms have been disconnected and/or removed entirely. Kitchen drawers and some appliance like mini fridge remain for a homely feeling to the resident’s room and for residents to store hydrating beverages. The activities room will be used as entertainment lounge and separate locked medication room for memory care residents only.

4th, 5th and 6th floor houses the assisted living for residents, multi-purpose room for dining and activities. Puzzles, game room and poker room for the residents.

Floors 7th and 8th : house the independent living residents, laundry room and lounge area (on each floor), and a library on the 7th floor.

There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. Stairwells have evacuation chairs. No bodies of water were observed at the facility. There is a shaded patio and garden area for residents. The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Medication rooms all observed with first aid kits in the kitchen, vehicles, activity room and in memory care. PPE storage located on the sixth floor.

During tour of the physical plant with Kay Cano, LPA did not observe any concerns regarding Health and Safety. Staff were observed to be assisting and engaging with the residents. The memory care unit was observed to be ready and in full compliances to house the memory care residents.

Exit interview held and a copy of the report was provided to Kay Cano.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC809 (FAS) - (06/04)

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