Facility Evaluation Report

Licensing Program Analyst (LPA) Luis De Leon conducted a Case Management- Incident visit to follow up on an incident report submitted to the Regional Office on 2/17/2025. LPA met with Assistant Administrator Denise Sutton. The purpose of today's visit is to check on the health & safety of residents in care.

On 7/13/2025, smoke was observed coming out from the breakout room in the basement. Pasadena Fire Department (PFD) arrived to facility and it was reported that source of smoke had been put out upon fire department arrival. Prior to leaving the facility, PFD toured the facility. PFD and Facility were not able to clear alarm on facility’s fire panel. As a result, PFD placed the facility on fire watch. Assistant Administrator Denis Sutton stated that she was present during the smoke alarm incident and stated that Pasadena Fire regulation does not require smoke detectors in the basement, only sprinkler systems. Since there was no fire, the fire sprinklers did not activate. The smoke was discovered when the elevator smoke detector was triggered. PFD cleared all floors but, before leaving, the facility was unable to reset the facility’s fire panel. Therefore, the facility was placed on fire watch until fire system company came on site to service the fire panel system at the facility. Assistant Administrator Denis Sutton confirmed that the facility was out of fire watch the following day on 7/14/2025. LPA toured the basement and observed there was no structural damage and no residents were injured. No health and safety issues were observed. No deficiencies were observed.

An exit interview was with Assistant Administrator Denise Sutton. A copy of the report and appeal rights were issued.