198603876-3-12-2026-28-AS-DKOI-DS4VFB-20260312162338

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603876
Report Date: 03/12/2026
Date Signed: 03/12/2026 04:24:47 PM

Document Has Been Signed on 03/12/2026 04:24 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	PREMIER HERITAGE OF PASADENA		FACILITY NUMBER:	198603876
ADMINISTRATOR/ DIRECTOR:	REYES,SHARON ROSE		FACILITY TYPE:	735
ADDRESS:	1202 SUNSET AVE		TELEPHONE:	(818) 468-6831
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY: 3		CENSUS: 2	DATE:	03/12/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:43 PM
MET WITH:	Sharon Reyes, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:35 PM

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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit. LPA met with Sharon Reyes, Administrator and LPA explained the purpose of the visit. The facility is licensed to care for three (3) ambulatory only Developmentally Disabled Adults, ages 18 through 59. All clients residing at this facility receive case management services provided by Frank D. Lanterman Regional Center.

LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tool and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located near the front door. Staff are adhering to infection control requirements. The facility has submitted the Infection Control Plan.

Operational Requirements: LPA observed updated Infection Control Plan in place. LPA observed valid Liability Insurance and Surety Bond are in place. Last Fire Drill was last conducted on 2/8/2026. Last Earthquake drill was conductee on 2/8/2026.

Physical Plant/Environment Safety: The facility is a single-story home located in a residential neighborhood that includes three (3) client bedrooms, two (2) bathrooms, living room, kitchen, dining room, backyard, staff office room, staff bedroom, and no garage. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Extra linen and towels are in the closet near the kitchen. Bathroom has non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PREMIER HERITAGE OF PASADENA	FACILITY NUMBER: 198603876
	VISIT DATE: 03/12/2026

NARRATIVE

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Physical Plant/Environment Safety [Cont.]: Backyard was inspected and observed clear of any obstructions and had a shaded area with patio furniture. Kitchen knives, sharps objects, are kept locked in a locked in a cabinet in the kitchen area and inaccessible to clients. Cleaning supplies are locked in a cabinet in the kitchen area and inaccessible to clients. LPA observed a fire extinguisher was fully charged and was purchased on 10/07/2025. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature reading in bathroom #1 was 117.6 deg F and 108.5 deg F which was within the required 105-120 degrees Fahrenheit. Based on record review, the licensee was issued to serve three (3) ambulatory clients based on the approved fire clearance dated 02/20/2025. However, LPA observed the facility is retaining one client, Client #1 (C1) who is non-ambulatory based on the physician’s report dated 05/13/2025.

Staffing: A total of five (5) staff including the Administrators provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared and have training.

Personnel Records/Staff Training: LPA reviewed four (4) staff files that included Personnel Record, Health Clearance, TB clearance, First Aid/CPR/AED training, Employee Rights, CPI training, and Staff training. Administrator's certificate expires on 04/26/2026. Administrator’s file has an updated HIV & TB training.

Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and they have access to the facility phone.

Food Service: The kitchen was inspected and the food preparation area and storage areas were observed to be clean and sanitary. There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. There are zero (0) client with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas.

Client Records-Incident Reports: LPA reviewed two (2) client files that include Face Sheet, Functional Capability Assessment, Admission Agreement, Physician's Report (including TB and Ambulatory Status), Individual Program Plan (IPP), and Personal Rights.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PREMIER HERITAGE OF PASADENA	FACILITY NUMBER: 198603876
	VISIT DATE: 03/12/2026

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Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed two (2) clients to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. LPA observed the First Aid kit that had all required items.

Incidental Medical Services: Per Administrator, there are no client at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. Facility maintains documentation of the required emergency drills.

Emergency Intervention: No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit will be documented on the LIC809-D. Exit interview was held and a copy of the report and appeal rights were provided to the Administrator, Sharon Reyes.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/12/2026 04:24 PM - It Cannot Be Edited

Created By: Daniel Konishi On 03/12/2026 at 04:11 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: PREMIER HERITAGE OF PASADENA	FACILITY NUMBER: 198603876
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80010(a)

Limitations on Capacity and Ambulatory Status

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee was issued to serve three (3) ambulatory clients based on the approved fire clearance dated 02/20/2025. However, LPA observed the facility is retaining one client, Client #1 (C1) who is non-ambulatory based on the physician’s report dated 05/13/2025. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/13/2026
	Plan of Correction
1 2 3 4	Licensee will get facility back into compliance by getting confirmation for ambulatory status sending Client #1 (C1’s) updated medical assessment or they will relocate Client #1 (C1) or request non-ambulatory fire clearance sending request to licensing and send LPA plan to correct.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

LIC809 (FAS) - (06/04)

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