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Inspection visit

Follow-up

PASADENA HIGHLANDSLicense 198603384
Clean visit · 0 citations

Inspector’s narrative

What the inspector wrote

On 09/27/24, Program Analyst (LPA) Vaid made an unannounced visit to the facility to conduct a Case Management visit to evaluate third floor -Memory Care, Health and Safety inspection. LPA met with Executive Director Kay Cano and explained the purpose for the visit. The Facility is an 8-floor building located in commercial /residential location. The facility has been renovated to expand housing for memory care residents from first floor to the third floor, housing memory care residents only. Dementia needs will be met on case by case basis. The facility has a new approved fire clearance LIC 850 dated 09/11/2024 and is approved for 245(two hundred fourty-five) non-ambulatory of which 30 (thirty) may be bedridden, hospice waiver for 30. There are currently 28 residents on hospice. Current request for increase to hospice population, awaiting approval. Delayed egress on the third floor and passed the inspection permit BLDMF2022-00588. Bedridden clients approved floor 3. Meet California Building Code 2022 435.5.1- smoke barriers. Three doors on the 3rd floor have the egress delay, each door at the end of hallways and on exit door by the elevators. The doors alarms will engage when attempting the push door open, 15 second delay with alarm blaring before doors open as per fire code. Conducted the 3rd floor inspection with maintenance director John Arbona, whom explained the delay egress process and tested the doors. Staff will have communication via walkie-talkies. 1st floor has a large dining room, common area, kitchen, salon, theater, fitness room, medication room, linen room, laundry room, trash room, club room, multipurpose room, billiard room, staff office, an elevator and public restrooms. The garden area has covered seating areas, walk around path and activities areas for the residents, a permanent garden is overseen by the residents. 2nd floor has lobby area 24 (twenty-four) rooms with bath, laundry room, employee break room, medication room, lobby, and staff office. CONTINUED on 809C........ 3rd floor will house the memory care residents, 1-2 residents per rooms. Dining room, activity room, laundry room. Egress alarms on three doors exiting the floor to the stairwell and each stairwell has evacuation chairs. The appliances in the memory care rooms have been disconnected and/or removed entirely. Kitchen drawers and some appliance like mini fridge remain for a homely feeling to the resident’s room and for residents to store hydrating beverages. The activities room will be used as entertainment lounge and separate locked medication room for memory care residents only. 4th, 5th and 6th floor houses the assisted living for residents, multi-purpose room for dining and activities. Puzzles, game room and poker room for the residents. Floors 7th and 8th : house the independent living residents, laundry room and lounge area (on each floor), and a library on the 7th floor. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. Stairwells have evacuation chairs. No bodies of water were observed at the facility. There is a shaded patio and garden area for residents. The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Medication rooms all observed with first aid kits in the kitchen, vehicles, activity room and in memory care. PPE storage located on the sixth floor. During tour of the physical plant with Kay Cano, LPA did not observe any concerns regarding Health and Safety. Staff were observed to be assisting and engaging with the residents. The memory care unit was observed to be ready and in full compliances to house the memory care residents. Exit interview held and a copy of the report was provided to Kay Cano.

Citations

No citations recorded on this visit

The inspector found no violations of California child care regulations during this visit.

FAQ · About this visit

Common questions about this visit

What happened during the September 27, 2024 inspection of PASADENA HIGHLANDS?

This was a other inspection of PASADENA HIGHLANDS on September 27, 2024. The inspection found no deficiencies and no citations were issued.

Were any citations issued to PASADENA HIGHLANDS on September 27, 2024?

No citations were issued during this inspection. The facility was found to be in compliance with all applicable regulations.

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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