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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222713
Report Date: 01/15/2026
Date Signed: 01/15/2026 04:36:55 PM

Document Has Been Signed on 01/15/2026 04:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PASA ALTA WESTFACILITY NUMBER:
191222713
ADMINISTRATOR/
DIRECTOR:		DEWALT BROWNFACILITY TYPE:
740
ADDRESS:1773 N. FAIR OAKSTELEPHONE:
(626) 398-9110
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 6DATE:
01/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Brisia Rojas, DSPTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required-1 year visit. Upon arrival, no one answered the door and LPA called the facility number. At 1:55pm, Brisia Rojas, DSP arrived and explained the purpose of the visit. At 2:00pm, Staci Mitchell, Administrator arrived and assisted LPA with the inspection. The facility is licensed to serve six (6) ambulatory adults 60 years of age or older with developmental disabilities. The facility is vendorized by the Frank D. Lanterman Regional Center.

LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tool and observed the following:

Infection Control: Staff are adhering to infection control requirements. The staff use disposable gloves to clean and disinfect the high touched surfaces in the common areas. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.

Physical Plant/Environment Safety: The facility is a single-story home which consists of: living room, dining area, kitchen, four (4) bedrooms (3 residents and 1 staff), two (2) bathrooms, one (1) staff bathroom, and laundry area. Resident bedrooms were inspected and closet/drawer space to accommodate each resident comfortably was available. LPA inspected residents’ rooms and each resident bedroom has the required furniture such as bed frames, dressers, nightstand, lamps, and chairs. Bedrooms also have sufficient closet space. Extra linens and towels are kept in a hallway closet. The bathrooms are clean and operational. The hot water temperature was tested throughout the facility. Hot water temperature were measured between 105.2 degrees F to 106.1 degrees F which are within the required 105 - 120 degrees F Smoke detectors and carbon monoxide detectors were tested and operable. Two (2) fire extinguishers were fully charged and last serviced on 05/02/2025.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASA ALTA WEST
FACILITY NUMBER: 191222713
VISIT DATE: 01/15/2026
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Physical Plant/Environment Safety [Cont.]: The front yard and backyard are free of debris/hazards and the outdoor and passageways are free of obstruction. A shaded area with chairs is provided in the back yard. There is no evidence of bodies of water (pool). Sharps are kept in a locked cabinet and are inaccessible to residents. All storage areas for cleaning solutions, toxins, and hazardous items are kept in a locked cabinet and are inaccessible to residents.

Operational Requirements: The facility has an approved fire clearance. Valid Infection Control Plan in place. Valid liability insurance and valid Surety Bond is in place. Last fire drill was conducted on 11/13/2025 and disaster drill was conducted on 12/20/2025.

Staffing: A total of ten (10) staff members including the Administrator and Licensee provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.



Personnel Records-Training: LPA reviewed four (4) staff files which include Personnel Record, Health Screening, TB Clearance, Employee Rights, First Aid/CPR/AED training, and Staff Training. However, the Administrator has a valid Adult Residential Facility (ARF) Administrator Certificate that expires on 01/20/2026 in file but does not have a valid Residential Care Facility for the Elderly (RCFE) Administrator certificate in file.

Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman.

Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents.

Food Service: Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. LPA observed an appropriate food supply of two (2) days of perishables and seven (7) days of non-perishables.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASA ALTA WEST
FACILITY NUMBER: 191222713
VISIT DATE: 01/15/2026
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Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed six (6) residents’ medications and there were no issues observed. The first-aid kit is fully stocked w/first-aid manual.

Resident Records-Incident Reports: Resident files are kept in a secure location (within staff room/office). LPA reviewed (6) Resident Files which includes the Face Sheet, Functional Capability Assessment, Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information, current Physician's Report, Ambulatory Status, TB Clearance, and Personal Rights. LPA reviewed Resident’s P&I.

Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least two (2) relocation sites.

Residents with Special Health Needs: There are no bedridden or residents with postural supports at this facility. Per the Administrator, there is no resident at this home with incidental medical services nor have a restricted health condition.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the Administrator Staci Mitchell.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/15/2026 04:36 PM - It Cannot Be Edited


Created By: Daniel Konishi On 01/15/2026 at 04:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASA ALTA WEST
FACILITY NUMBER: 191222713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87406(a)
(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and staff interview, the Administrator does not have a valid Residential Care for the Elderly Administrator Certificate but has a Adult Residential Facility Administrator Certificate that expires on 01/20/2026. This poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2026
Plan of Correction
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Licensee will ensure that the Administrator has a valid Residential Care Facility for the Elderly (RCFE) Administrator Certificate and send a copy of the RCFE Administrator Certificate to the LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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