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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603952
Report Date: 06/09/2021
Date Signed: 06/09/2021 10:26:04 AM

Document Has Been Signed on 06/09/2021 10:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PROSPECT MANORFACILITY NUMBER:
197603952
ADMINISTRATOR:LYDIA PABIONFACILITY TYPE:
740
ADDRESS:800 PROSPECT AVETELEPHONE:
(626) 799-1141
CITY:SOUTH PASADENASTATE: CAZIP CODE:
91030
CAPACITY: 99CENSUS: 46DATE:
06/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Lydia Pabion - AdministratorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst(s) Mary Flores and Nina Galarza conducted a second case management visit during a case management visit to follow up on incident report dated 6/4/21.

During the tour of the facility staff #1 (S1) was observed with face covering under chin not covering nose or mouth and staff #2 (S2) removed mask as we conducted tour as S2 stated to be feeling out of breath which poses an immediate health, safety, or personal rights risk to residents in care and staff. Per CDC, and Community Care Licensing COVID 19 recommendations staff should wear a face covering while at the facility.

Based on Title 22 Division 6 Chapter 8 deficiencies will be cited on LIC 809D.

Exit interview was conducted with Lydia Pabion administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/09/2021 10:26 AM - It Cannot Be Edited


Created By: Mary G Flores On 06/09/2021 at 09:49 AM
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: PROSPECT MANOR
FACILITY NUMBER: 197603952

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2021
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in all Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidence by:
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Licensee will ensure that staff at using their face mask or face covering at all times by submitting LIC 9098 and in service training related to proper wearing of face covering by 6/10/21.
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Based on observation LPA(s) observed staff #1 and staff #2 wearing their mask not covering their nose and mouth which poses an immediate health, safety, and personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Rebecca Orendain
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2021


LIC809 (FAS) - (06/04)
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