PASADENA HIGHLANDS

Official classification

Type A

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in rodent droppings were observed underneath the shelfing units in the corners by the walls. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/06/2026 Plan of Correction Cleared at the time of visit. Director provided LPA with proof of scheduled pest management appointment for 1/7/25. Maintenance cleaned the areas in which the droppings were observed by LPA during today's visit. LPA, observed the area to ensure it was cleared of rodent droppings.

Official classification

Type A

Official code

1569.50(a)(3)

Regulation authority

HSC

What the official deficiency says

(a)(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the front desk did not comply with the section cited above in 2 of 2 counts which poses an immediate health, safety or personal rights risk to persons in care. Front dest staff did not screen for COVID-19 symptons or check temperture of LPAs when greeted at arrival to facility.

Official plan of correction

POC Due Date: 02/04/2022 Plan of Correction Administrator will address how facility will correct the screening and temperture check for visitors arriving at facility and send writen statement by POC date.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

(5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews, the facility did not comply with the section cited above for one resident in room #223 as LPA, Administrator and Nurse Laura all observed medications in resident's room which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/04/2022 Plan of Correction Facility removed the medications from the residents's room druing visit. Aministrator will conduct training for staff on medication handling and storing and will send log with staff signatures to LPA by POC date.

Official classification

Type A

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements. Within 24 hours the licensee shall notify the licensing agency (and the local health officer, if appropriate) if an epidemic outbreak, poisoning, catastrophe or major accident which threatens the welfare, safety, or health of residents, personnel or visitors occurs. Facility had outbreak of Covid -19 (first of 12 individuals tested positive on 12/25/2021 and not reported untill 01/12/2022) and did not report to health department and licensing agency as required

Official plan of correction

The administrator will submit an incident report regarding outbreak. Also, shall provide in service training to staff regarding reporting requirements. Submit proof to CCL by POC date. Every covid positive must have Speical incident report within 24 hours.

Deadline recorded: Feb 4, 2022. A deadline is not proof that correction was completed.