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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603384
Report Date: 06/09/2021
Date Signed: 06/09/2021 03:39:28 PM

Document Has Been Signed on 06/09/2021 03:39 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PASADENA HIGHLANDSFACILITY NUMBER:
198603384
ADMINISTRATOR:CANO, KAYFACILITY TYPE:
740
ADDRESS:1575 E WASHINGTON BLVDTELEPHONE:
(801) 815-0808
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 245CENSUS: 147DATE:
06/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Brodey DeBorde, Executive DirectorTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted a Case Management-Deficiencies visit due to observations made during complaint control #: 28-AS-20210607141758 visit. LPA met with Executive Director Brodey DeBorde and explained the purpose of the visit.


The following were observed/inspected:
  • At 10:59 am LPA tested the two delayed egress exit doors in the memory care unit. They require a manual code to enter/exit. The main delayed egress door was not working properly. The right side of the door did not open after the delayed egress time of 15 seconds, nor did the alarm sound off. Executive Director also tested the door.

  • The facility currently does not have displayed in the main entry of the facility the required poster that contains information on the appropriate reporting agency in case of a complaint as per Senate Bill 895 (Corbett), Chapter 704, Statutes of 2014. This law became effective January 1, 2015. LPA conducted a tour of the 1st and 2nd floor lobby entrance areas determined that the poster was not displayed as required. Administration confirmed the CDSS Let Us No poster is not posted anywhere in the facility.


Deficiencies are cited in LIC 809D.

Exit interview conducted with Executive Director Brodey DeBorde. Appeal Rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2021
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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Document Has Been Signed on 06/09/2021 03:39 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/09/2021 at 01:14 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: PASADENA HIGHLANDS
FACILITY NUMBER: 198603384

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2021
Section Cited
CCR
87705(j)

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87705(j) Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement was not met by evidence of:
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Administrator agrees provide proof of delayed egress door repairs/replacements, and conduct inservice training regarding testing the delayed egress system for all exits by POC due date.
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Based on observation at 10:59 am during the delayed egress door testing in the memory care unit, as a part of a complaint investigation it was observed the right door did not open after the delayed egress time of 15 seconds. In addition, the alarm did not sound off on that door. The left side door was operable. This poses an immediate health and safety risk.
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Type B
06/10/2021
Section Cited
HSC1569.33(i)(1)(2)

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1569.33(i)(1)(2) Unannounced inspections; notification of deficiencies; compliance; reports. The department shall design, or cause to be designed, a poster that contains information on the appropriate reporting agency in case of a complaint or emergency.Each residential care facility for the elderly shall post this poster in the main entryway of its facility.
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Administrator agreed to post the required poster that contains information on the appropriate reporting agency in case of a complaint. Submit photographs as proof of correction.
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Based on physical plant observation with Health and Wellness Director a complaint poster with DSS/CCLD complaint phone number was not observed in the 1st and 2nd floor main entryway areas.
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2021


LIC809 (FAS) - (06/04)
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