198603584-3-27-2023-28-AS-KRAZ-CQBULZ-20230327154130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603584
Report Date: 03/27/2023
Date Signed: 03/27/2023 03:42:21 PM

Document Has Been Signed on 03/27/2023 03:42 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	LOS ROBLES GUEST HOME		FACILITY NUMBER:	198603584
ADMINISTRATOR:	AVILA, LEAH		FACILITY TYPE:	735
ADDRESS:	1657 N LOS ROBLES		TELEPHONE:	(626) 797-0808
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY: 12		CENSUS: 7	DATE:	03/27/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:28 AM
MET WITH:	Administrator Avila		TIME COMPLETED:	12:15 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez and Erik Zaragoza conducted an announced pre-licensing visit and met with Administrator Avila. LPA’s inspected physical plant. This facility will serve 12 clients of which 2 may be non-ambulatory. This facility will serve level 2 developmentally disabled adults ages 18 – 59 years old and will be receiving services from Frank D Lanterman Regional Center. Fire clearance was approved by Pasadena Fire Department on 01/5/23.

The facility is a two-single story home located on a residential street. The facility consists of enclosed front yard, living room, one staff office, kitchen, dining room, two (2) lounge/sitting area, 8 client bedrooms, 5 client bathrooms, detached garage, and enclosed backyard.

FIRST FLOOR OBSERVATIONS: The tour began at 9:33 am and was led by Administrator Avila. LPA’s observed front of facility to be free from hazards and no large bodies of water were observed. LPAs observed living room area to be clean and contain plenty of lighting and seating. LPAs observed a digital thermostat located near hallway and inside temperature read 74 degrees F. Kitchen was observed to be clean and LPAs observed appliances to be in working order. A refrigerator was stocked with plenty of perishable foods. Non-perishable foods were also observed and properly stocked. At 9:42 am, LPAs observed kitchen cabinet containing sharps to be accessible to residents in care. Administrator Avila acknowledged the lock was not working properly and immediately removed all sharps from cabinet and secured sharps in nearby garage. At 9:45 am, LPAs observed kitchen cabinet directly located under kitchen sink to be accessible to residents in care. Administrator Avila acknowledged the lock was not working properly and immediately removed all cleaning solutions/disinfectants nearby garage. Client bedrooms 1- 4 all contained the required furniture, linen, and lighting. Private bathroom#1 located in client bedroom#1 light fixture was not working properly. Water temperature in private bathroom#1 was measured at 118.7 degrees F which is within 105 – 120 degrees F. Lounge area was observed to be clean, and several fire extinguishers were observed to be fully charged throughout first floor. Shared bathroom #2 water temperature was measured at 122.7 degrees which in not within the required 105- 120 degrees F. Shared bathroom#2 was observed to be clean and LPAs observed signs promoting hand washing. Private bathroom#3 located in client bedroom# 3 water temperature was measured at 121.4 degrees F which is not within the required 105 – 120 degrees F. Client bedrooms 1- 4 are approved for non-ambulatory.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

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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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: LOS ROBLES GUEST HOME	FACILITY NUMBER: 198603584
	VISIT DATE: 03/27/2023

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SECOND FLOOR OBSERVATIONS: Client bedroom 5 – 8 all contained the required furniture, linen, and lighting. Private bathroom# 4 located in client bedroom# 6 water temperature was measured at 119.4 degrees F, which is. LPAs observed signs promoting hand washing. Shared client bathroom# 5 water temperature was measured at 114.2 degrees F. LPAs observed signs promoting hand washing.

Rear cottage/accessory structure is not approved for client use.

CORRECTIONS REQUIRED:

1. Replace/fix cabinet lock containing sharps and knives.

2. Replace/fix cabinet lock containing disinfectants/cleaning solutions.

3. Maintain water temperature in shared bathroom #2 under 120 degrees F.

4. Maintain water temperature in private bathroom #3 under 120 degrees F.

5. Replace/fix light fixture in bedroom #1.

LPA will return once all items are corrected and redo inspection.

Exit interview conducted with Administrator Avila.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC809 (FAS) - (06/04)

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