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Inspection visit

Routine inspection

PASADENA HIGHLANDSLicense 1986033842 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Alberto Lopez and Noemi Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Brodie Deborde and explained the purpose of the visit. Administrator certificate expires June 9, 2023 Last fire drill was on 12/28/2021 Structure: The Facility is a 8th floor building with 245 bedrooms, on the 1st floor, there's one huge dining room, one small dining area for memory care unit, a restaurant style kitchen, library, club room, living room, theater, fitness room, salon, medication room, 10 shared bedrooms, 10 bathrooms, a restaurant style kitchen, and an elevator and public restroom. 2nd floor has 26 rooms, 3 rd and 4 th floor has 29 rooms. from 5th to 8th floor, has 30 apartments with bedrooms and bathrooms, laundry room and lounge area. There is a large garden area on the premises with covered tables and chairs. All the resident’s bedrooms and apartments are spacious and will easily accommodate the resident's furnishings. The passageway and walkways are free of hazard and free from obstruction. On today's tour, LPA was able to review all 36 bedrooms and memory care unit. Facility has 25 hospice waivers. Currently there are 23 hospice residents. The following were observed/inspected: · COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept. · LPAs were not screened for this visit. · Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing. · Facility has one designated isolation room. · Thirty six client rooms, common areas, bathrooms, and outdoor physical plant was inspected. · Nine client rooms were not equipped with alcohol-based hand sanitizer. · Four (4) centrally stored client medication records were reviewed. · Staff responsible for direct care and supervision were observed wearing masks. · Clients were not observed wearing masks but adhering to public health social distance guidelines. · Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed. · A posted Emergency Disaster Plan was not observed posted but was at facility. · PPE's were observed. · Staff and resident files were not reviewed during today's visit. · Deficiencies cited per Title 22 Health and safety code, See 809D for details. · Exit interview was conducted with Assistant Administrator Lara P. Morris. A copy of the report was provided.

Citations

5 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.

  • 87465(a)(5)Type A

    Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed.This requirement is not met as evidenced by: Based on interviews conducted and record review on Jan. 1, 2022 (R1) was not administered evening medication as directed by MD. The meidications were administered late, were not crushed, and the wrong inhaler was taken to the room. Staff (S6) acknowledged medication error. This poses an immediate health and safety risk.

  • 87411(a)Type B

    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: Based on record review and interviews conducted between October 2021- January 2022 the facility has experienced staffing shortages. Resident (R1) required total care, but was not being checked by staff as indicated in the re-assessment.This poses a potential health and safety risk to residents in care.

  • 87464(f)(4)Type B

    Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. Based on record review and interviews conducted resident (R1) required repositioning, incontinence care, and feeding assistance after return from hospitalization. R1 had a change in condition due to injury sustained on 10/20/21. Assistance was not provided in a timely manner. This poses a potential health and safety risk to residents in care.

  • 87468.2(a)(4)Type B

    Additional Personal Rights of Residents in Privately Operated Facilities. In addition to ... Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:Based on interviews and record review resident (R1) fell in the lobby area on 10/20/21. R1 was without assistance, but per Care Plan R1 requires escort assistance. This poses a potential Health and Safety risk to residents in care.

  • 1569.50(a)(3)Type A

    Based on observation, the front desk did not comply with the section cited above in 2 of 2 counts which poses an immediate health, safety or personal rights risk to persons in care. Front dest staff did not screen for COVID-19 symptons or check temperture of LPAs when greeted at arrival to facility.

FAQ · About this visit

Common questions about this visit

What happened during the February 3, 2022 inspection of PASADENA HIGHLANDS?

This was a inspection inspection of PASADENA HIGHLANDS on February 3, 2022. 2 citations were issued: 2 Type A (serious).

Were any citations issued to PASADENA HIGHLANDS on February 3, 2022?

Yes, 2 citations were issued (2 Type A, 0 Type B). The first citation was for: "Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when..."

What type of inspection was this?

This was a inspection inspection. inspection 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.