<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603384
Report Date: 12/16/2022
Date Signed: 12/30/2022 09:03:24 AM


Document Has Been Signed on 12/30/2022 09:03 AM - 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:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director, Kay CanoTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced TA site visit along with Pasadena Public Health Dept. Representatives, Casey Cortes (PHN) and Sandy Gesell (PHN). LPA and PPHD representatives met with Executive Director, Kay Cano and explained the purpose of today's visit. Afterward, Sanda Lee, Assisted Living Director and John Arbona, Director of Plant Operations joined and assisted with the tour of the facility. The joint visit was initiated to assist the facility in reducing their Covid-19 positive cases.

Census: 154 residents (19 MC)

Observations:
  • The facility is closed for new admission (12/08/2022) and are in response testing.
  • Testing is continued to be performed 2x/week on Tuesdays and Fridays.
  • Activities, communal areas (main/large dining room, theater, salon, fitness/exercise room, library) are all closed temporarily due to the outbreak.
  • Staff deliver food to the residents rooms in disposable containers.
  • There is no designated green, yellow, or red zone; Residents isolate in their own rooms.
  • Precaution sign/notification indicating covid positive resident isolating in the room was posted on the door.
  • Automatic hand sanitizer dispensers were placed at the entrances of the facility, by the elevator in the 2nd/main floor, public restrooms and entrance to memory care unit.
  • Pump hand sanitizers were on the PPE carts outside the rooms of covid positive residents.
  • Staff sanitize the common areas, door handles, elevator twice (2x) a day, morning and afternoon using one step Disinfectant Deodorizer Cleaner (DDC).
  • Housekeepers are on-site to clean high-touch surfaces including door handles, side rails, and elevator buttons. Staff use diluted DDC in a spray bottle and interchange it with Lysol wipes. This process is also done 2x a day.
  • All staff in the kitchen wore face coverings and disposable gloves. Staff have been re-trained on how to disinfect/clean their areas, food carts. PPEs like masks and disposable gloves are available throughout the kitchen.
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
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Entrance
  • All visitors entering the building are instructed to take their temperature. The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet. Visitors must fill out information in a binder at the front to verify that they do not have symptoms of COVID-19.
  • 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.

Assisted Living/Independent Living (Floors 2-8)
  • 2 Medtechs per shift
  • In emergencies (e.g. falls), Medtechs stay and assist the resident and call Wellness Director, Britany Bruner to perform assessments.
  • Isolation carts, signage, and hand sanitizers are placed outside of COVID-19 positive resident rooms. A total of 2 rooms with 2 residents each were observed to be COVID-19 positive.
  • Isolation carts have enough PPEs available. One PPE cart ran out of disposable gloves, but immediately re-stocked.
  • Residents were observed wearing masks. Some who were wearing masks incorrectly or had their mask below the chin are reminded by the staff to wear it properly.
  • Masks are available to residents upon request and are placed inside their rooms.

Memory Care (Floor 1, locked unit)
  • 4 Staff – 1 activities staff, 2 caregivers, and 1 Medtech
  • Isolation carts, signage, and hand sanitizers are placed directly outside the unit.
  • Donning and doffing are performed outside the unit.
  • All residents, including COVID-19 positive residents, were observed wearing masks.
  • Cleaning of all surfaces is performed every 2 hours or 2x a day.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2