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Inspection visit

Follow-up on corrections

PASADENA HIGHLANDSLicense 1986033842 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Galarza conducted a Case Management-Deficiencies visit due to observations made during complaint control #: 28-AS-20210607141758 visit. LPA met with Executive Director Brodey DeBorde and explained the purpose of the visit. The following were observed/inspected: At 10:59 am LPA tested the two delayed egress exit doors in the memory care unit. They require a manual code to enter/exit. The main delayed egress door was not working properly. The right side of the door did not open after the delayed egress time of 15 seconds, nor did the alarm sound off. Executive Director also tested the door. The facility currently does not have displayed in the main entry of the facility the required poster that contains information on the appropriate reporting agency in case of a complaint as per Senate Bill 895 (Corbett), Chapter 704, Statutes of 2014. This law became effective January 1, 2015. LPA conducted a tour of the 1st and 2nd floor lobby entrance areas determined that the poster was not displayed as required. Administration confirmed the CDSS Let Us No poster is not posted anywhere in the facility. Deficiencies are cited in LIC 809D. Exit interview conducted with Executive Director Brodey DeBorde. Appeal Rights were issued.

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87411(a)Type A

    87411(a) Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement was not met by evidence of: On June 4, 2021 at approximately 1:30 pm resident (R1) eloped out of the facility after exiting the memory care unit delayed egress door without staff knowlede when staff (S6) exited out, and did not ensure the door closed properly. This posed an immediate safety risk to this resident in care.

  • 1569.33(i)(1)(2)Type B

    1569.33(i)(1)(2) Unannounced inspections; notification of deficiencies; compliance; reports. The department shall design, or cause to be designed, a poster that contains information on the appropriate reporting agency in case of a complaint or emergency.Each residential care facility for the elderly shall post this poster in the main entryway of its facility. Based on physical plant observation with Health and Wellness Director a complaint poster with DSS/CCLD complaint phone number was not observed in the 1st and 2nd floor main entryway areas.

  • 87705(j)Type A

    87705(j) Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.This requirement was not met by evidence of: Based on observation at 10:59 am during the delayed egress door testing in the memory care unit, as a part of a complaint investigation it was observed the right door did not open after the delayed egress time of 15 seconds. In addition, the alarm did not sound off on that door. The left side door was operable. This poses an immediate health and safety risk.

FAQ · About this visit

Common questions about this visit

What happened during the June 9, 2021 inspection of PASADENA HIGHLANDS?

This was a other inspection of PASADENA HIGHLANDS on June 9, 2021. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to PASADENA HIGHLANDS on June 9, 2021?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "87411(a) Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent ..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.