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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603680
Report Date: 03/18/2025
Date Signed: 03/18/2025 04:50:23 PM

Document Has Been Signed on 03/18/2025 04:50 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HAMPTON GUEST HOME, INC.FACILITY NUMBER:
197603680
ADMINISTRATOR/
DIRECTOR:		YANG, ERLINDAFACILITY TYPE:
740
ADDRESS:3790 HAMPTON RD.TELEPHONE:
(626) 351-1215
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 5DATE:
03/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:43 PM
MET WITH:Jeffrey Yang - Facility Manager DesigneeTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Jeffrey Yang and explained the reason for the visit.

The facility is licensed to serve 6 non-ambulatory residents age 60 and above. Facility has a dementia waiver and are allowed to care for 1 resident on hospice at any one time. The facility is a single-story home, located in a residential area. It consist of; an administrator office room, kitchen, living room, family room, dining room, 6 resident bedrooms, 1 staff bedroom, 3 resident bathrooms, 1 staff bathroom, a detached garage, a front yard and backyard.

LPA reviewed the following CARE inspection tool domains during this visit:

Infection Control: Infection control plan was reviewed which meets current regulations. Hand sanitizer and proper sanitation was observed during the visit. Each staff has a current TB test. There is a responsible person and emergency training was provided to staff. Personal protective equipment was observed.
Operational Requirements: Facility maintains a plan of operation. Facility has a current liability insurance. Facility is operating within the license.
Physical Plant/Environmental Safety: LPA conducted a tour of the facility with Jeffrey Yang and observed the following: Facility was observed in good repair indoors and outdoors. Living room/family room/dining room are all clean, and providing sufficient sitting area, and lighting.A fireplace was observed in the living room covered. Kitchen area is clean, sharps were observed locked in a drawer. Each resident room (6) were observed clean with sufficient lighting, furniture, and bedding supplies. Bathrooms (3) were observed clean in working condition with grab bars and skid mats in the showers. Water temperature was tested in each bathroom and tested between 106.3 - 111.0 degrees F., which is within the required 105-120 degrees F. Garage is used to stored cleaning supplies, laundry area is located in garage and it is not accessible to the residents. (CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAMPTON GUEST HOME, INC.
FACILITY NUMBER: 197603680
VISIT DATE: 03/18/2025
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Backyard has shaded sitting area and a 5ft fence surrounds the pool making it inaccessible to the residents. Carbon Monoxide/Smoke detectors were observed, tested, and in working condition. Fire extinguishers were observed and last checked on 12/6/23. Ramps, exit doors, and passageways are free of debris and obstructions.
Staffing: Jeffrey Yang is the appointed facility manager designated. Staff have current CPR/First Aid training on file. Night staff have been provided with emergency training. Sufficient staff were observed.
Personnel Records/Staff Training: Administrator certificate was observed for Jeffrey Yang #7002701740 exp. date: 12/1/25. All staff records were available for review. LPA reviewed a total of 4 staff files which included medical assessment, TB clearance, background clearance, and training. Staff training files were not on file for the last 20 hours of yearly training.
Resident Rights/Information: Personal Rights, Let Us No poster (PUB 345), and Local Ombudsman posters were observed throughout the home.
Planned Activities: Activity materials were observed. Activities were provided during the visit. All residents were involved. Outdoor area has a seating area to promote outdoor activities.
Food Service: Sufficient food supplies were observed of perishables for at least 2 days and non-perishables for at least 7 days. Staff are familiar with special diets identify by residents' physicians. No pest was observed.
Incidental Medical and Dental: All medication is centrally stored in the living room in a lock cabinet. Medications are label and in their original containers. PRN medication dispensed is recorded in a log.
Resident Records/Incident Reports: Residents records were available for review. LPA reviewed a total of 5 resident files which contained medical assessment, TB clearance, admission agreement, an appraisal, a needs and care plan.
Disaster Preparedness: Emergency Disaster plan (LIC 610D 3/19) was last reviewed on 2/7/25. Emergency drills are conducted quarterly and the last emergency drill was conducted on 1/29/25.
Residents with Special Health Needs: Postural support/bed rails were observed and physician's request were observed in residents files. There are no residents with restricted health conditions under care. Facility is following dementia regulations. Medical assessments for 2 residents with dementia were observed not within the last 12 months. Staff have requested the assessment and are pending. Auditory devices were observed in each exit door. Facility currently has one resident on hospice and keeps hospice plan on file.
No deficiencies were noted during this visit. Technical violations were noted.
Exit interview was conducted with Jeffrey Yang and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC809 (FAS) - (06/04)
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