198603384-1-6-2026-28-AS-MCOA-DQ42BY-20260106161556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603384
Report Date: 01/06/2026
Date Signed: 01/06/2026 04:16:10 PM

Document Has Been Signed on 01/06/2026 04:16 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/ DIRECTOR:	KAY CANO		FACILITY TYPE:	740
ADDRESS:	1575 E WASHINGTON BLVD		TELEPHONE:	(801) 815-0808
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY: 245		CENSUS: 212	DATE:	01/06/2026
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:04 AM
MET WITH:	Kay, Cano, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	04:25 PM

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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Annual Continuation – Case Management visit today. LPA, met with Kay Cano, Executive Director, and the reason for the visit was explained. The facility is licensed to serve 245 non-ambulatory residents ages 60 and over, of which 30 may be bedridden on 1st and 2nd floors, there is an approved delayed egress and Hospice waiver for 35. There are currently 26 residents on hospice. Kay Cano and John Arbona, Maintenance Director, facilitate today’s visit which focused on inspecting the physical plant.

The facility is an 8-story building located in Pasadena. A tour of the facility included:

*The 1st floor:

Large dining room, kitchen, salon, theater, fitness room, linen room, laundry room, trash room, club/TV room, billiard room, staff office, multipurpose area, family living room area, an elevator, two gender specific public restrooms and 20 shared resident rooms with bathrooms.
*The 2nd floor:
Lobby area ,24 resident rooms with bathrooms laundry room, employee break room, medication room, lobby, and staff office.
*The 3rd floor:
Houses the Memory Care unit, 12 shared and 16 private resident rooms, two dining rooms, activity room, staff laundry room, game room, room and activity alcove. The unit has Egress alarms on three doors exiting the floor to the stairwell.
*The 4^th floor:
Game room and alcove, staff studio, laundry room and 29 resident rooms with bathrooms.
***Continues on LIC 809-C****

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

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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Document Has Been Signed on 01/06/2026 04:16 PM - It Cannot Be Edited

Created By: Mayra Cota On 01/06/2026 at 02:03 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: 01/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in rodent droppings were observed underneath the shelfing units in the corners by the walls. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/06/2026
	Plan of Correction
1 2 3 4	Cleared at the time of visit. Director provided LPA with proof of scheduled pest management appointment for 1/7/25. Maintenance cleaned the areas in which the droppings were observed by LPA during today's visit. LPA, observed the area to ensure it was cleared of rodent droppings.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:

	Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

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: 01/06/2026

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*The 5th floor:
Casino-style room, laundry room, and 30 resident rooms with bathrooms.
^The 6th floor:
Computer alcove, laundry room and 30 resident rooms with bathrooms.
*The 7^th floor:
Library, laundry room and 30 resident rooms with bathrooms.
The 8th floor:
Laundry room, quiet/resting spots and 30 resident rooms with bathrooms.

The following was observed during today’s inspection:

The facility was observed clean inside and out. Walkways, passages, exits, ramps, hallways and staircases were observed free of debris and obstruction. Furniture in the common areas is kept in good repair. During today’s visit, 23 resident rooms were inspected. Rooms were observed to have the required furniture and bedding. Water temperature was tested in resident bathrooms and measured between 106.3-119.4 degrees F which is within compliance range. Each resident room has a call button in the bedroom and a pull cord in the bathroom. Call buttons and pull cords were observed operational. Each resident room has individual smoke detectors which were tested and working properly. The dining rooms were inspected and were found to be clean, and sufficient seating is available for residents. The kitchen was inspected, and food preparation areas, stoves, refrigerators and freezers are kept clean and maintain adequate temperatures. The facility has sufficient 2-day perishable and 7-day non-perishable supply of food. Food is kept properly stored and within expiration limits. Cooking utensil room and dry/canned food pantry were inspected; however, rodent droppings were observed underneath the shelfing units in the corners by the walls. The outdoor environment has a covered seating area, walking path and sport areas and a resident garden.

Fire extinguishers were observed throughout the building on every floor. Fire extinguishers were observed charged and readily available for use. Facility staff conduct safety drills monthly and last drill was conducted on 12/16/25. Facility’s fire alarm and sprinkler system are inspected annually, and the last inspection was completed on 5/19/25. Pasadena Fire Department inspected the facility for Fire and Life safety on 6/16/25 and no violations were noted, according to records reviewed today. Evacuation chairs were observed on each staircase and are kept in good repair. The 6^th floor houses the facility’s incontinence care and PPE supplies. The kitchen houses an emergency supply of food and water.

***Continues on LIC 809-C page 2***

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

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: 01/06/2026

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The facility has three vehicles which are used for resident transportation to appointments and outings. Keys for vehicles are kept in the main office. Reviews of records indicate that vehicle maintenance and repairs are being conducted regularly. Vehicle insurance and registrations are kept up to date.

During today’s visit, LPA interviewed 16 residents and three staff. A deficiency was noted and citation issued. Exit interview was conducted with Kay Cano, Executive Director, and a copy of this report, 809-D and Appeal Rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

LIC809 (FAS) - (06/04)

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