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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603391
Report Date: 02/17/2022
Date Signed: 02/17/2022 01:57:34 PM

Document Has Been Signed on 02/17/2022 01:57 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:HASTINGS RANCH HOMEFACILITY NUMBER:
198603391
ADMINISTRATOR:ESTANISLAO, RALPHFACILITY TYPE:
740
ADDRESS:1230 HASTINGS RANCH RDTELEPHONE:
(626) 351-1150
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 4DATE:
02/17/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Evelyn Mercado - CaregiverTIME COMPLETED:
02:15 PM
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced plan of correction visit to follow up on deficiencies given during annual visit conducted on 2/7/22.

During the annual visit conducted on 2/7/22 LPA Flores observed the following deficiencies:

Section 87303(e)(2) Maintenance and Operation - On 2/7/22 LPA Flores tested water temperature in resident's bathrooms and were tested at; Bathroom #1(B1) at 121.6 degrees F, bathroom #2(B2) at 121.3 degrees F, bathroom #3(B3) at 128.0 degrees F., During today's visit water temperature was tested as follow in B1 tested at 114.1 degrees F., B2 tested at 113.5 degrees F., and B2 tested 114.7 at degrees F., which is within the required 105-120 degrees F. Deficiency cleared on 2/17/22.

Section 87309(a)(1) Storage Space - On 2/7/22 LPA Flores observed chemicals and cleaning solutions not locked during the visit. During today's visit LPA observed cabinet under sink and cleaning supplies have been removed. Deficiency cleared on 2/7/22.

Exit interview was conducted with Evelyn Mercado caregiver and a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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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