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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603779
Report Date: 09/24/2024
Date Signed: 09/24/2024 12:16:20 PM

Document Has Been Signed on 09/24/2024 12:16 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:ALTAPAS CARE CENTERFACILITY NUMBER:
198603779
ADMINISTRATOR/
DIRECTOR:		GALEANO, DAYSIFACILITY TYPE:
735
ADDRESS:2011 N. SUMMIT AVETELEPHONE:
(626) 823-6117
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 0DATE:
09/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:12 AM
MET WITH:Gary Hall - Applicant
Daysi Galeano - Applicant/Administrator		TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an announced Pre-Licensing facility Evaluation visit. LPA met with Applicants Gary Hall and Daysi Galeano (Administrator) who assisted LPA with the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The Infection Control Plan has been submitted to CCL and the CAB Analyst. The facility has an Infection Control Training Plan. Emergency Disaster Plan is current and posted. Staff will adhere to infection control requirements.


Physical Plant & Environment Safety: The facility is a single-story home in a residential neighborhood. It contains three (3) bedrooms, two and a half (2 1/2) bathrooms, a living room, kitchen, dining area, laundry area, backyard, and basement. A separate house in the back securely fenced and with a different address is currently occupied by the Applicants. Fire clearance granted for (4) ambulatory and (2) non ambulatory, (0) bedridden clients. Bedrooms are large enough to allow for easy passage and have the required items of furniture. There are 2 1/2 bathrooms in the home that have grab bars and non skid mats in the shower room. There are sufficient supply of linens available to permit weekly changing are available. Sufficient personal hygiene supply available. Smoke/Carbon monoxide detectors were observed throughout the home and were tested and operable. (3) fire extinguishers were observed which were purchased on 06/12/2024.ยท Cleaning solutions and sharps were locked and stored separately from where food supplies are stored. Kitchen cabinets, refrigerator/freezer, oven, microwave, dishwasher are in working condition, clean and sanitary. No pools or bodies of water were observed in or around the property. There are no firearms present at the property. The home does not have a video camera monitor system inside and outside the property. Hot water temperature readings were within the Title 22 Regulations requirement. Between 9:45am-10:02am, hot water readings were as follows: bathroom #1 at 108.2 deg F, bathroom #2 at 112.3 deg F and the 1/2 bathroom at 111.0 deg F.

***CONTINUED ON LIC 809-C*****

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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: ALTAPAS CARE CENTER
FACILITY NUMBER: 198603779
VISIT DATE: 09/24/2024
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Operational Requirements: The facility has a fire clearance granted by the City of Pasadena Fire Department on 09/17/2024. Fire clearance granted for (4) ambulatory, (2) non ambulatory and (0) bedridden. The applicant has a valid Surety bond in the amount of $4000. One (1) operating telephone was observed and tested on the premises. Telephone is easily accessible and available for clients' use. Sample menu was observed posted on the bulletin board. There is a covered outdoor patio area that is furnished for outdoor use. Equipment and supplies for indoor activities was observed and available for use.
Personnel Records: All personnel records will be maintained in the facility. Administrator has a valid Administrator certificate expiring in 01/15/2026.
Client Records: All client records will be maintained in the facility. Administrator will ensure that all client records shall be available to CCL to inspect. Administrator will obtain and keep on file documents of clients' medical assessment
Food Service: Meals will be stored and prepared in a safe manner, necessary to meet the needs of clients. Toxic substances are stored in a locked cabinet. Food storage and preparation areas, which include pantries, cupboards, drawers and counters were observed to be clean and appropriate for food preparation. Appliances such as a microwave, refrigerator and stove were observed to be clean and operating properly. The refrigerator was observed to be at 45 degrees Fahrenheit and the freezer at 0 degrees Fahrenheit. Health Related Services: First Aid supply with all the required supplies was observed and is kept in a kitchen cabinet. Medication will be kept in a safe and locked place inaccessible to clients.
Disaster Preparedness: The home has a complete Emergency and Disaster Preparedness Plan that includes, EVAC Procedures, transportation arrangements, location of all utility shut-off valves and instructions for use. There is a contact information list of local emergency response personnel, clients authorized representative or local emergency contact name posted on the board in the hallway.

Component III was also completed at the time of the visit and all required documents for Licensing were discussed. Facility met the physical plant requirements/ inspection as required per California Code of Regulations Title 22 Division 6.

LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the pre-licensing facility evaluation visit report.

Exit interview conducted and a copy of this report was provided to Gary Hall - Applicant and
Daysi Galeano - Applicant/Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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