Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Tricia Pedroza (Owner) and Estefany Lopez (Administrator) and explained the purpose of today’s visit. The facility is licensed to serve 90 Ambulatory only adults ages 18 through 59.

The facility is located in Pasadena, CA. A tour of the facility includes: a total of 49 rooms and 20 bathrooms, there are 5 buildings, the main building and 4 cottages. There are two levels in the main building, 4 single story cottages (E1-E4) and covered patio area on the grounds. The main structure has 23 bedrooms, men's and women's bathrooms on lower and upper levels, a dining room, kitchen with pantry and walk-in fridge, tv/living room, activity room, office, medication room and a laundry room. North-Wing consists of 4 down stairs rooms and 5 upstairs rooms, and bathrooms, E1 consist of 6 bedrooms and one bathroom, E2 consists of 4 bedrooms and one bathroom, E3 consists of 4 bedrooms and one bathroom and E4 consists of 4 bedrooms and one bathroom.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.

Physical Plant & Environment Safety: Smoke detectors and carbon monoxide detectors are operable and in compliance. Bathrooms are clean and operational, LPA did observe shower in Unit E3 was observed to have a leak, details will be cited on the 809-D page. 12 clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises.