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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603566
Report Date: 10/17/2022
Date Signed: 10/17/2022 09:31:07 AM


Document Has Been Signed on 10/17/2022 09:31 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:ASTORIA PARK SENIOR LIVINGFACILITY NUMBER:
198603566
ADMINISTRATOR:GOODLETT, BRIANNAFACILITY TYPE:
740
ADDRESS:925 EAST VILLA STREETTELEPHONE:
(626) 796-4303
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:220CENSUS: 80DATE:
10/17/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
08:19 AM
MET WITH:Gina Lopez - StaffTIME COMPLETED:
09:45 AM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted a case management visit to follow up on corrections needed during pre-licensing visit conducted on 9/12/22. LPA Flores met with Brianna Goodlet - applicant's representative.

On 9/12/22 LPA Flores, Mora, and Ramirez observed the following corrections needed:

Applicant is to fix the loose outlet cover plate in room #145 and hole in the wall in room #103.
Applicant is to ensure the water temperature is maintain between 105 and 120 degrees F. in rooms #160, 159, 156, 153, 152, 150, 149, 145, 141, 139.
Applicant is to ensure bathrooms in rooms #141 and 153 have skid strips/mats.
Applicant is to ensure resident #1(R1) in room#155 and resident #2(R2) #256 do not store medication in their rooms.

On 10/17/22 LPA Flores conducted a tour with Gina Lopez - staff and observed the following:
Cover plate in room #145 was installed.
Hole in wall in room #103 was repaired.
Water temperature in rooms # 160, 159, 156, 153, 152, 150, 149, 145, 141, 139 was tested and tested between 110.3 to 117.8 degrees F., which is within the required water temperature.
Skid strips were observed in rooms #141 and 153 showers.
No medication observed in room #155 and in room #256 resident #2 has medication but an updated physician's report dated 9/19/22 indicates resident can stored on medication.

Physical plant is following Title 22 Regulations. Exit interview was conducted with Brianna Goodlet - Applicant's Representative and a copy of this report was provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
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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