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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603531
Report Date: 11/07/2023
Date Signed: 11/07/2023 12:58:41 PM

Document Has Been Signed on 11/07/2023 12:58 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:FAIR OAKS MANORFACILITY NUMBER:
198603531
ADMINISTRATOR:ALMERO, CARMENFACILITY TYPE:
735
ADDRESS:1753 N. FAIR OAKS AVE.TELEPHONE:
(626) 345-9788
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 14CENSUS: 10DATE:
11/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Carmen Almero- AdministratorTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with facility Administrator, Carmen Almero, and explained the purpose for the visit. The facility is a two-story building, operating as an Adult Residential Facility, licensed to serve (14) ambulatory adults, ages 18-59, of which (2) may be non-ambulatory.
During today's visit, LPA Maldonado conducted a tour of the physical plant with Administrator, observed the facility food supplies, reviewed (5) client medications, (5) client files, (3) staff files, and conducted interviews with (3) staff and attempted to interviews with (3) clients. Five (5) random resident bedrooms were inspected and had the required furniture, storage space, and lighting. There were (2) full bathrooms and (1) half-bathroom. Full bathrooms had the required grab bars and non-skid mats. The water was tested and measured at 109*F, which is in compliance. The food supplies was observed to be the required 2-day perishables and 7-day non-perishables, as well as emergency food and water supplies available. Fire extinguishers were observed throughout the premises, with current inspections and fully charged. Walkways and ramps were observed to be free of debris and obstructions/hazards. Sharps were observed stored in the kitchen, inaccessible to clients in care. Toxins and cleaning supplies were observed stored in the storage room downstairs and underneath the kitchen sink, locked and inaccessible to clients in care. Centrally stored medications were also observed stored in a cabinet, inaccessible. Laundry equipment was observed in good repair and operational during the visit. Sufficient linens, towels, and personal hygiene supplies were available. The facility has an approved mitigation plan on file and a current infection control plan submitted to the department. Sufficient PPE supplies were observed. Smoke/carbon monoxide detectors were observed in each room. Last fire drill was 10/15/23. Staff and resident files were reviewed for required documentation. LPA observed that files for Staff#2 & #3 were missing proof of required annual training. Per the Administrator, training has been conducted but she does not have proof/records of the training completed. The Administrator's Certificate is current with expiration date of: 02/25/2025. Resident's medications were reviewed and observed to be documented properly and given as prescribed.
During today's visit, deficiencies were observed and cited on the LIC809-D page.
An exit interview conducted with Administrator. A copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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 11/07/2023 12:58 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/07/2023 at 12:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAIR OAKS MANOR
FACILITY NUMBER: 198603531

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80022(e)(4)
Plan of Operation
(e) If the licensee intends to admit or care for one or more clients who rely upon others to perform all activities of daily living, the plan of operation must also include a statement that demonstrates the licensee's ability to care for these clients. The evidence of ability may include but not be limited to: (4) Documentation of training the licensee and/or staff have completed specific to the needs of these clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in2 of 3 staff do not have proof of required annual training available in their files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Administrator will submit proof of completed required annual training for Staff# 2 and #3 to LPA, via email, by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
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