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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603391
Report Date: 12/12/2022
Date Signed: 12/12/2022 01:08:57 PM

Document Has Been Signed on 12/12/2022 01:08 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HASTINGS RANCH HOMEFACILITY NUMBER:
198603391
ADMINISTRATOR:ESTANISLAO, RALPHFACILITY TYPE:
740
ADDRESS:1230 HASTINGS RANCH RDTELEPHONE:
(626) 351-1150
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 6DATE:
12/12/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Alma Pasion - Caregiver TIME COMPLETED:
01:20 PM
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced plan of correction (POC) visit for deficiencies given during annual visit conducted on 12/6/22. LPA met with Alma Pasion caregiver and explained the reason for the visit.

On 12/6/22 LPA Flores conducted an annual visit and noted the following deficiencies:

Section 87465(h)(1) Incidental Medical and Dental Care Services: On 12/6/22 LPA Flores observe prepared medication in cups was observed under the computer desk, overflow medication was observed in the garage. On 12/12/22 LPA observed medication was under lock in medication cabinet. Deficiency cleared as of 12/12/22.

Section 87608(a)(3) Postural Supports: On 12/6/22 LPA Flores observed residents had bed rails in the sides of their beds and no physician's order were on file for resident #1(R1), #2(R2), #4(R4), and #6(R6). On 12/12/22 LPA observed a physician order for half bed rails for R1, R2,R4,R6. Deficiency cleared as of 12/12/22.

Section 87608(a)(5)(B) Postural Supports: On 12/6/22 LPA Flores observe resident #2(R2)'s bed was observed with full bed rails, R2 is not under hospice care. On 12/12/22 LPA observed R2 has half bed rails and a physician order is in place. Deficiency cleared as of 12/12/22.

Exit interview was conducted with Alma Pasion caregiver and a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2022
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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