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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603384
Report Date: 02/03/2022
Date Signed: 02/03/2022 04:57:01 PM

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:
02/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Brodie Deborde, AdminstratorTIME COMPLETED:
04:56 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez and Noemi Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Brodie Deborde and explained the purpose of the visit. Administrator certificate expires June 9, 2023 Last fire drill was on 12/28/2021

Structure:
The Facility is a 8th floor building with 245 bedrooms, on the 1st floor, there's one huge dining room, one small dining area for memory care unit, a restaurant style kitchen, library, club room, living room, theater, fitness room, salon, medication room, 10 shared bedrooms, 10 bathrooms, a restaurant style kitchen, and an elevator and public restroom. 2nd floor has 26 rooms, 3rd and 4th floor has 29 rooms. from 5th to 8th floor, has 30 apartments with bedrooms and bathrooms, laundry room and lounge area. There is a large garden area on the premises with covered tables and chairs. All the resident’s bedrooms and apartments are spacious and will easily accommodate the resident's furnishings. The passageway and walkways are free of hazard and free from obstruction. On today's tour, LPA was able to review all 36 bedrooms and memory care unit. Facility has 25 hospice waivers. Currently there are 23 hospice residents.

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· LPAs were not screened for this visit.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility has one designated isolation room.
· Thirty six client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Nine client rooms were not equipped with alcohol-based hand sanitizer.
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.50(a)(3)
Suspension and Revocation
(a)(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the front desk did not comply with the section cited above in 2 of 2 counts which poses an immediate health, safety or personal rights risk to persons in care. Front dest staff did not screen for COVID-19 symptons or check temperture of LPAs when greeted at arrival to facility.
POC Due Date: 02/04/2022
Plan of Correction
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Administrator will address how facility will correct the screening and temperture check for visitors arriving at facility and send writen statement by POC date.
Type A
Section Cited
CCR
87465(a)(5)
Incidental Medical and Dental Care Services
(5) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the facility did not comply with the section cited above for one resident in room #223 as LPA, Administrator and Nurse Laura all observed medications in resident's room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2022
Plan of Correction
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Facility removed the medications from the residents's room druing visit. Aministrator will conduct training for staff on medication handling and storing and will send log with staff signatures to LPA by POC date.
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 YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/03/2022
NARRATIVE
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· A posted Emergency Disaster Plan was not observed posted but was at facility.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
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Deficiencies cited per Title 22 Health and safety code, See 809D for details.
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Exit interview was conducted with Assistant Administrator Lara P. Morris. A copy of the report was provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC809 (FAS) - (06/04)
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