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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603384
Report Date: 01/12/2022
Date Signed: 02/03/2022 05:22:45 PM

Document Has Been Signed on 02/03/2022 05:22 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: 154DATE:
01/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Bordie Deborde, Adminitrator over the phoneTIME COMPLETED:
03:31 PM
NARRATIVE
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Licensed Program Analyst (LPA) Alberto Lopez, Spoke with Administrator Brodie Deborde While conducting Covid-19 Positive intakes for 12 individuals, LPA Alberto Lopez asked Administrator why he had not reported the Covid positives and he stated that staff is working double shifts and he is getting results late. LPA reminded Administrator of his obligation to report within 24 hours.

Reporting Requirements. Within 24 hours the licensee shall notify the licensing agency (and the local health officer, if appropriate) if an epidemic outbreak, poisoning, catastrophe or major accident which threatens the welfare, safety, or health of residents, personnel or visitors occurs.

Citation issued for not reporting Covid outbreak.

See 809D for details
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/03/2022 05:22 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/13/2022 at 10:29 AM
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: 01/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2022
Section Cited
CCR
87211(a)(2)

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Reporting Requirements. Within 24 hours the licensee shall notify the licensing agency (and the local health officer, if appropriate) if an epidemic outbreak, poisoning, catastrophe or major accident which threatens the welfare, safety, or health of residents, personnel or visitors occurs.
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The administrator will submit an incident report regarding outbreak. Also, shall provide in service training to staff regarding reporting requirements. Submit proof to CCL by POC date. Every covid positive must have Speical incident report within 24 hours.
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Facility had outbreak of Covid -19 (first of 12 individuals tested positive on 12/25/2021 and not reported untill 01/12/2022) and did not report to health department and licensing agency as required
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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:Christine Yee
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2022


LIC809 (FAS) - (06/04)
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