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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603391
Report Date: 01/28/2025
Date Signed: 01/28/2025 04:01:49 PM

Document Has Been Signed on 01/28/2025 04:01 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:HASTINGS RANCH HOMEFACILITY NUMBER:
198603391
ADMINISTRATOR/
DIRECTOR:		ESTANISLAO, RALPHFACILITY TYPE:
740
ADDRESS:1230 HASTINGS RANCH RDTELEPHONE:
(626) 351-1150
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 4DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Marissa Carreon - CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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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 Marissa Carreon and explained the reason for the visit.

The facility is licensed to serve 5 non-ambulatory and 1 bedridden residents over the age of 60, with an approved hospice waiver for 6. The facility has 5 bedrooms, 3 bathrooms, a living room, a dining room, a TV room, a kitchen and an attached garage. The outdoor facility has a front yard, and back patio.

LPA toured the facility with Marissa Carreon and observed the following:
All common areas: Living room, dining room, and TV area are clean with furniture in good repair. Fireplace located in the living room is covered. A/C vent in TV area's ceiling is full of dust mites. Required posters were observed in the living room. Each resident rooms (5) have sufficient lighting, the required furniture, lighting, and bedding supplies. Room #1 has a piece of frame wood coming off on the exit door to the patio. Room # 2's bed was observed with full bed rails, resident is no longer in hospice. Room #5 has a dresser that has 3 broken drawers. Three (3) bathrooms were observed each is in working condition, showers have grab bars and skid mats. Water temperature was tested between 105.0-106.8 degrees F., which is within the required 105-120 degrees F. Kitchen was observed clean. Sharps were observed locked in a drawer. Medication cabinet was observed locked. Sufficient food supplies were observed. Cleaning supplies were observed in the garage. Garage is used as storage. Smoke/ Carbon Monoxide detectors were observed and tested. Fire extinguisher was observed mounted in the kitchen and last checked on 12/30/24. Facility has auditory devices in each door as they serve dementia residents. Sound device in front door, exit door to garage, room #1, and room #4 were not on during the visit. Backyard, passageways, and front yard are free of debris and have shaded seating area. Main entrance exit door was observed with a lock that requires a key from both sides inside and outside. Facility has one item to promote activities, or activity schedule was observed.

LPA reviewed medication for 3 residents, and files for 4 residents. Resident #2(R2) has PRN medication prescribed that has been log provided each day for the month of January. (CONTiNUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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 13
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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391
VISIT DATE: 01/28/2025
NARRATIVE
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However, The date and time the PRN medication was taken, the dosage taken, and the resident's response are not documented. R2 was found not to be on hospice and a full bed rail was observed in their bed. R2's admission agreement was missing signature. No hospice initiation or discontinuation were observed or submitted to the department for R2 and R3.

LPA reviewed 3 staff files. Staff #3(S3) was cleared and associated to the facility on 3/1/24 and has only 24 hours of initial training. LPA reviewed LIC 500 - Personnel Record and it list 3 staff schedule to work Saturday- Sunday between 6am-6pm. No additional staff files for review, no night staff was listed, and LPA observed both staff working the morning shift.

LPA reviewed Infection control plan and emergency disaster plan. Per disaster drill log, drills were conducted on 7/6/24 and 12/1/24.

LPA interviewed 3 resident and 2 staff.

Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 01/28/2025 04:01 PM - It Cannot Be Edited


Created By: Mary G Flores On 01/28/2025 at 02:16 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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(l)(2)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in main entrance has a key lock on both sides (inside and outside) and a key is required to open the door which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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Administrator will contact request a new fire clearance to allow lock in main exterior door or will switch lock that allows one latch system indoor and submit a copy of fire clearance request or picture of new lock by POC due date 1/29/25.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 01/28/2025 04:01 PM - It Cannot Be Edited


Created By: Mary G Flores On 01/28/2025 at 02:16 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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87413(a)(1)
Personnel - Operations
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in after reviewing LIC 500 personnel record only list 3 staff and no additional staff records were available for review in case the regular staff is not available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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3
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Administrator will ensure to have additional staff to cover regular staff when absent by either hiring on call staff or through a registry agency and will submit LIC 500 or a plan to cover staff when absent to the department by POC due date: 2/6/25.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in door in room #1 has a piece of frame sticking out, vent in bathroom #2 is hanging by the ceiling, vent in TV area is covered in dust mites, dresser in room #5 has 3 drawers broken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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Administrator will repair the above items and will submit pictures of the repairs to the department by POC due date: 2/6/25.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 01/28/2025 04:01 PM - It Cannot Be Edited


Created By: Mary G Flores On 01/28/2025 at 02:16 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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in S3's training was reviewed and only has 24 hours of training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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Administrator will provided additional 14 hours of training to the S3 and will provide copies of training to the department by POC due date 2/6/25.

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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 01/28/2025 04:01 PM - It Cannot Be Edited


Created By: Mary G Flores On 01/28/2025 at 02:16 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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Services (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in R2 has one PRN medication that has been provided daily for the month of January and it has not been tracked properly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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Administrator will provide staff training in recording PRN medication per the regulation, will ensure staff record it properly, and will submit a copy of training provided with topic/duration/signatures to the department by POC due date: 2/6/25.
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.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
Page: 6 of 13
Document Has Been Signed on 01/28/2025 04:01 PM - It Cannot Be Edited


Created By: Mary G Flores On 01/28/2025 at 02:16 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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in drills were provided in a period of six months apart which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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Administrator will ensure to provide disaster drills each quarter and will certify in writing that will conduct drills each quarter to the department by POC due date: 2/6/25.
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on observation and record review, the licensee did not comply with the section cited above in R2 has a full bed rail on the bed and R2 discontinued hospice on January 2025 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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Administrator will discuss with R2's physician on plan for R2 to either have a half bed rail request and a half bed rail place in bed or submit an exception request to the department to have R2 retain the full bed rail to the department by POC due date: 2/6/25.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
Page: 7 of 13
Document Has Been Signed on 01/28/2025 04:01 PM - It Cannot Be Edited


Created By: Mary G Flores On 01/28/2025 at 02:16 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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in R3 does not have a hospice plan copy available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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2
3
4
Administrator will obtain a copy of R3's hospice plan and will ensure when an update is done to obtain a copy and will submit a copy to the department by POC due date: 2/6/25.
Type B
Section Cited
CCR
87705(c)(4)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in LIC 500 Personnel Record list 3 staff schedule between 6am - 6pm Saturday-Sunday which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
1
2
3
4
Administrator will ensure there is a night staff available, will update LIC 500 to reflect, and submit a copy to the department by POC due date: 2/6/25.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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