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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603421
Report Date: 05/05/2022
Date Signed: 05/05/2022 12:04:37 PM


Document Has Been Signed on 05/05/2022 12:04 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:GRANT SERENITY HOMES OF SIERRA MADRE, INC.FACILITY NUMBER:
198603421
ADMINISTRATOR:GEVORKIAN, NVARDFACILITY TYPE:
740
ADDRESS:425 N. SIERRA MADRE BLVDTELEPHONE:
(818) 425-6797
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 4DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Lourdes Sandoval - Caregiver
Nvard Gevorkian - Administrator 		TIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on the infection control domain, food, and medication review. LPA Flores met with Lourdes Sandoval caregiver and explained the reason for the visit. Administrator Nvard Gevorkian arrived 30 minutes later.

Facility is licensed to served 6 bedridden residents over the age of 60 and serves residents with dementia. Facility has a hospice waiver for 6. The indoor facility has 6 bedrooms, 2 bathrooms, a living room, a dining room, a kitchen and a detached garage. The outdoor facility has a front yard, and back yard. Facility has a sound auditory device in entry and exit doors. No large bodies of water were observed. Smog/Carbon monoxide detectors were observed, tested, and are in working condition. Fire Extinguisher was observed outside bedroom #1 and current.

LPA Flores toured the facility with Lourdes Sandoval Caregiver and observed the following:
Living/dining room has sufficient sitting area, activities were observed for residents in care.
Kitchen was observed to maintain sufficient food for at least 2 days of perishables and 7 days of non-perishables. Sharps, cleaning supplies, and medication were observed locked.
All bedrooms have sufficient lighting, furniture, and bedding. Bathroom #1 is used for visitors and staff, residents do not use the shower, water temperature was tested at 111.6 degrees F. Bathroom #2 was observed to have grab bars and skid mat in the shower, cabinets with hygiene products and cleaning supplies were locked, and water temperature was tested at 109.8 degrees F. LPA Flores reviewed 5 residents medication and files and 3 staff files. Staff #2 is missing TB test. Administrator Certificate observed #6050643740 exp:12/23/22
Facility is following COVID recommendations regarding cleaning, screening, social distancing, and monitoring. N95 Fit testing for staff must be conducted and TB test for staff #2.
Deficiency has been noted on LIC 809D per Title 22 Regulations Chapter 6 Division 8.
Exit interview was conducted with Nvard Gevorkian administrator and a copy of this report, LIC809D, technical advisory, and appeal rights were provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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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Document Has Been Signed on 05/05/2022 12:04 PM - It Cannot Be Edited

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: GRANT SERENITY HOMES OF SIERRA MADRE, INC.
FACILITY NUMBER: 198603421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 3 staff, staff #2 does not have a TB test/Chest x ray on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2022
Plan of Correction
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Administrator will ensure staff #2 obtains TB test clearance and will submit a copy to the department via fax by POC date 5/19/22.

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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
LIC809 (FAS) - (06/04)
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