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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603384
Report Date: 12/16/2022
Date Signed: 12/16/2022 01:36:42 PM


Document Has Been Signed on 12/16/2022 01:36 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:PASADENA HIGHLANDSFACILITY NUMBER:
198603384
ADMINISTRATOR:DEBORDE, BRODYFACILITY TYPE:
740
ADDRESS:1575 E WASHINGTON BLVDTELEPHONE:
(801) 815-0808
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:245CENSUS: 154DATE:
12/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Kay CanoTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit focusing on Infection Control Domain. LPA met with Executive Director Kay Cano and explained the purpose of the visit. At 9:30am, LPA met with representatives from Pasadena Public Health Dept., Casey Cortes (PHN) and Sandy Gesell (PHN) to do a joint/TA visit. Short time later, LPA and PPHD representatives were joined by Sanda Lee, Assisted Living Director and John Arbona, Director of Plant Operations and assisted with the tour of the facility.

Structure:
The facility is licensed to care for individuals age range 60 and over, 245 non-ambulatory, of which 30 may be bedridden. It is approved for delayed egress and for bedridden on 1st and 2nd floors with approved exits. The building consists of eight (8) floors with 245 bedrooms. First (1st) floor consists of: one (1) large dining room, one (1) small dining area for memory care unit, a restaurant style kitchen, computer/library room, club room, living room, theater, fitness/occupational therapy room, salon, medication room, ten (10) shared bedrooms, ten (10) bathrooms, 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 and serve as visitation area during covid. 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. Facility has 25 hospice waivers. Currently there are 23 hospice residents.

At 10:30am, the following were observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet.
  • COVID-19 signage was placed in several areas of the facility. Visitors are screened in the main entrance and a log is kept.
  • LPA was 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 hand washing, cough/sneeze etiquette, and physical distancing.
  • PPEs were observed. Facility maintained a 30-day supply of PPE located in the supply room in the 6th floor.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Residents were observed to be wearing masks and adhering to public health social distance guidelines.
  • Maintenance/building personnel disinfect the common areas, door handles, elevators twice (2) a day. Staff use DDC disinfectant. Housekeepers use a diluted DDC in a spray bottle and interchange it with lysol wipes to clean.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASADENA HIGHLANDS
FACILITY NUMBER: 198603384
VISIT DATE: 12/16/2022
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  • The kitchen was inspected and LPA was met by Wayne Scott, Director of Dining Services. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All the appliances are cleaning and are working properly.
  • Kitchen staff were observed wearing masks and using disposable gloves. PPEs like masks and disposable gloves are available around the kitchen area.
  • Cleaning solutions and sharps were locked and inaccessible.
  • LPA inspected fifteen (15) resident rooms. Each bedroom has a smoke detector (in the bedroom and bathroom), bed, linen, dresser, night stand, light, chair and sufficient closet space. Resident rooms are also equipped with a pull system life alert.
  • Common areas, public restrooms, and outdoor physical plant were inspected. All common areas and residents activities are temporarily closed until PPHD gives the clearance.
  • Temporarily, meals are being delivered in the residents rooms in disposable containers and residents use disposable utensils.
  • Assisted Living rooms were equipped with alcohol based hand sanitizer. There were no hand sanitizers kept inside the Memory Care residents rooms for safety reasons. However, hand sanitizers are kept in a cabinet and ready in the medication room if someone needs it.
  • Bathrooms have the required grabs bars, non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Public restrooms contained the required hygiene supplies.
  • One (1) laundry room is available for residents' use in each floor.
  • Medications were locked, centrally stored, and given as prescribed. Medications were reviewed for six (6) residents and facility maintained a 30-day supply of medications.
  • Residents' medications were reviewed to confirm medication is given as prescribed and is documented properly.
  • The garden patio has ample shaded area and sitting area. The area is designated as the visitor area for the COVID-19 pandemic.
  • There are cameras in the common areas (no audio), but there were no cameras seen in private areas.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • Fire extinguishers were observed to be fully charged and last serviced Nov. 2, 2022. There were four (4) fire extinguishers per floor.
  • Administrator certificate expires January 16, 2024.
  • Staff and resident files were not reviewed during today's visit.


No deficiencies cited during this visit. Exit interview was conducted with Executive Director Kay Cano and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC809 (FAS) - (06/04)
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