<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603961
Report Date: 01/30/2026
Date Signed: 01/30/2026 11:39:51 AM

Document Has Been Signed on 01/30/2026 11:39 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PASADENA ASSISTED LIVING INC.FACILITY NUMBER:
198603961
ADMINISTRATOR/
DIRECTOR:		MINSHULL, ARMENFACILITY TYPE:
740
ADDRESS:3949 SYCAMORE ST.TELEPHONE:
(818) 601-7839
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 0DATE:
01/30/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Applicants Armen Minshull and Artoor MinassiTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Elena Mallett and Bonnie Tao conducted an announced pre-licensing visit on 01/30/2026 with Applicants Armen Minshull and Artoor Minassi. The fire clearance is approved for six (6) residents, ages 60 and over and six (6) can be non-ambulatory. The applicant has submitted a request for 6 hospice waivers to the Centralized Applications Bureau (CAB). Administrator certificate is current and the expiration date is 05/01/26. Currently, no resident is residing at the facility.

Infection Control:

The licensee has developed an Infection Control Plan and designated a lead staff to conduct training. Facility has sufficient PPE supplies and will provide on-going training to staff on infection control.

Operational Requirements:

The facility has a dementia care plan to accept or retain residents with dementia. The audio device at the exit for resident safety was observed to be operable.

Structure/Physical Plant:

The facility is a single-story home in the residential area of Pasadena. It consists of four (4) resident bedrooms, an open living room, dining room area, laundry room, a kitchen, four (4) full resident bathrooms and (1/2) one half bathroom for guests and staff. The home is well-maintained and passageway is free of obstruction. Bedroom room #1 and Bedrooms #2 are private rooms for non-ambulatory residents. Bedrooms #3 and #4 are shared rooms for non-ambulatory residents. (- continued in LIC 809C-)

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2026
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 4
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)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASADENA ASSISTED LIVING INC.
FACILITY NUMBER: 198603961
VISIT DATE: 01/30/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
All rooms were observed to have the required furnishings and in compliance. Common areas have night lights. Bathrooms have non-skid mats in the shower area and grab bars. The backyard has a shaded area with 2 tables and chairs sufficient for number of residents. The backyard is free of obstructions and debris and has a ramp to assist residents. Residents’ rooms have adequate lighting, the required bedroom furniture and in compliance. Extra linens and hygiene supplies were observed.

No swimming pool or bodies of water are on the premises. The toilets were functioning properly and the hot water temperature was measured in the range of 109-110.5 degrees F which is within the Title 22 requirements. The outside side gate has a latch and is able to open from the outside.

Facility has an operable smoke detectors in each room and two in the living room. Two carbon monoxide detectors were located near resident rooms. A fully charged fire extinguisher was mounted on the wall near the kitchen. Knives, sharps, cleaning solutions, and disinfectants are locked and inaccessible to residents. No firearms or weapons stored at the facility. The facility has an auditory device on each exit door.

Food Service:

Two days of perishable and seven days of non-perishable food are observed. The food is stored separate from cleaners, poisons and toxins. The kitchen kept clean and sanitary. The appliances were all observed to be operable to prepare and store food. Sufficient amount of tableware, dishes, and utensils are observed. There are two refrigerators that are both maintained at 40 degrees F or below and the freezer at 0 degrees F or below.

Staff and Residents files:

Staff / Residents files and medication will be stored in a locked cabinet in the laundry room.

Planned Activities:

The facility has sufficient space to accommodate indoor and outdoor activities. A list of planned activities was provided and supplies for activities are observed.

Incidental Medical and Dental:

Medications will be centrally stored and locked inside a cabinet in the laundry room. The first aid kit was observed to contain all the required supplies along with the current first aid manual. (continued in LIC 809C)

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASADENA ASSISTED LIVING INC.
FACILITY NUMBER: 198603961
VISIT DATE: 01/30/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Disaster Preparedness:

The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. There was emergency food, water and lights observed.

Residents with Special Health Needs:

The facility will accept and retain residents with dementia and/or hospice. The facility phone is operable. All required postings were observed .

Exit:

No issues were observed during the visit. Component III was conducted with the applicants. Liability insurance shall be secured upon licensure.

An exit conference was completed with applicants Artoor Minassi and Armen Minshull. A copy of LIC 809 has been furnished to applicant. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application they has been instructed to communicate with the CAB Analyst who assigned to their application.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4