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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603421
Report Date: 04/01/2025
Date Signed: 04/01/2025 04:39:25 PM

Document Has Been Signed on 04/01/2025 04:39 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:GRANT SERENITY HOMES OF SIERRA MADRE, INC.FACILITY NUMBER:
198603421
ADMINISTRATOR/
DIRECTOR:		ANI KARAPETYANFACILITY TYPE:
740
ADDRESS:425 N. SIERRA MADRE BLVDTELEPHONE:
(818) 425-6797
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 6DATE:
04/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Lourdes Sandoval - CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:55 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 Lourdes Sandoval caregiver and explained the reason for the visit.

Facility is licensed to serve 6 non-ambulatory residents over the age of 60, of which (6) may be bedridden, and has a hospice waiver for (6). The facility is a single home in a residential area and consist of a kitchen, a living/dining room, with 6 resident rooms, 2 bathrooms, a laundry area, a detached garage, a front yard, and a back yard.

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. There is a responsible person and emergency training was provided to staff. Personal protective equipment was observed. Plan was last reviewed on 6/10/24.
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 Lourdes Sandoval and observed the following: Facility was observed in good repair indoors and outdoors. Living room/dining room is clean, and providing sufficient seating area, and lighting. Kitchen area is clean and inaccessible to residents, sharps, medication, and cleaning supplies were observed locked in cabinets in the kitchen area. Six (6) resident rooms were observed clean with sufficient lighting, furniture, and bedding supplies. Full bed rails were observed in bedroom #2 and #3. (CONTINUED ON LIC 809C)
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2025
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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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GRANT SERENITY HOMES OF SIERRA MADRE, INC.
FACILITY NUMBER: 198603421
VISIT DATE: 04/01/2025
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Two (2) Bathrooms were observed clean in working condition with grab bars. Bathroom #2 was observed with no skid mat in the shower. Water temperature was tested between 111.5 - 112.5 degrees F., which is within the required 105-120 degrees F. Laundry room was observed in good repair. Activities were observed in a cabinet in the living room. Front yard and back yard have a shaded seating area. Garage is used to stored additional food supplies. There are no large bodies of water in the facility.
Carbon Monoxide/Smoke detectors were observed, tested, and in working condition. Fire extinguishers were observed and last checked on 10/8/24. Ramps, exit doors, and passageways are free of debris and obstructions.
Staffing: Designee staff Diana Castellano arrived at the facility shortly after. Staff have current CPR/First Aid training on file. Night staff have been provided emergency training. Sufficient staff were observed.
Personnel Records/Staff Training: Administrator certificate was observed for Ani Karapetyan #6066778740 exp. date: 6/28/25. All staff records were available for review. LPA reviewed a total of 5 staff files which included medical assessment, TB clearance, background clearance, and training.
Resident Rights/Information: Personal Rights, Let Us No poster (PUB 475), and Local Ombudsman posters were observed posted in the kitchen and living room.
Planned Activities: Activity materials were observed. Per staff a contractor visits the home to provide music therapy and activities are provided daily by staff. 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. There are currently no residents on special diets. No pest was observed.
Incidental Medical and Dental: There is an area designated to centrally stored medication in a cabinet with a lock in the kitchen. Medications are label and in their original containers. Staff have a log for PRN medications provided.
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, medication sheet.
Disaster Preparedness: Emergency Disaster plan (LIC 610E 3/19) was last reviewed on 3/5/25. Last Emergency drill was conducted on 1/5/25. Record reviewed showed facility conducts quarterly drills.
Residents with Special Health Needs: Postural support/bed rails were observed and physician's request were observed in residents files.
(CONTINUED ON LIC 809C)
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
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: GRANT SERENITY HOMES OF SIERRA MADRE, INC.
FACILITY NUMBER: 198603421
VISIT DATE: 04/01/2025
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However, two residents; resident #1(R2) was observed to have four half bed rails, two in each side of the bed and #3(R3) was observed to have full bed rails in the bed. R1 and R3 are currently not receiving hospice services. There are no residents with restricted health conditions under care. Facility is following dementia regulations. Medical assessments for residents with dementia were observed within the last 12 months. Auditory devices were observed in each exit door. Facility currently has one resident on hospice and keeps hospice plan on file.

Deficiencies were noted per Title 22 Regulations and a technical violation was noted.

Exit interview was conducted with Administrator and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/01/2025 04:39 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/01/2025 at 03:42 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: GRANT SERENITY HOMES OF SIERRA MADRE, INC.
FACILITY NUMBER: 198603421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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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Based on observation and record review, the licensee did not comply with the section cited above in R1 and R3 have full bed rails on their beds and are not receiving hospice care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2025
Plan of Correction
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Administrator will submit either an exception request with physician's order and family request to the department or will switch the full rail to a half bed rail and submit the pictures to the department by POC due date 4/1/25.
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.
Tony Vasallo
NAME OF LICENSING PROGRAM MANAGER:
Mary G Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2025


LIC809 (FAS) - (06/04)
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