Facility condition and maintenance
Cited in 3 reports, with 3 deficiencies in total.
207 WEST CARTER AVENUE, Sierra Madre CA 91024
6 bedsLatest official report Sep 25, 2025Licensed
The available records show 2 Type A and 2 Type B deficiencies for this facility.
1 later report, on Sep 25, 2025, recorded no deficiencies, though the records do not say whether they were follow-ups.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
Counts cover the five-year public record. Typical figures are the median for the 1,564 Los Angeles County facilities licensed for 6 or fewer beds.
In the available public five-year record, CCLD published 5 reports for this facility: 5 inspections, 0 complaint investigations, and 0 licensing or administrative records.
Those records contain 2 Type A and 2 Type B deficiencies.
1 deficiencies have explicit official correction or clearance evidence in the loaded records.
More than the typical 4
2 in the last 12 months
More than the typical 1
1 in the last 12 months
Most this size have none
1 in the last 12 months
Most this size have none
0 in the last 12 months
Most this size also have none
0 in the last 12 months
Last 36 months
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Cited in 3 reports, with 3 deficiencies in total.
All preserved reports from the most recent to the oldest, sortable by report type.
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the hot water used by residents to attain a temperature of not less than 105-degree F (41 degree C) and not more than 120-degree F (49 degree C) This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, LPA tested hot water temperature and measured readings were 106.1 deg. F in bathroom #1, 123.6 deg F in bathroom #2 and 125.03 deg F in bathroom #3 which is not within the required temperature 105 to 120 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2025 Plan of Correction Administrator shall immediately adjust the water temperature. Administrator to check water temperature at various different times throughout the day and maintain and submit a water temperature log to the LPA for the next 3 days to ensure that hot water temperature falls within 105-degree F and 120 degrees F. Administrator will provide a copy of the log to the department once water temperature falls within Title 22 guidelines.
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the Administrator did not comply with the section cited above in that the gallon of milk stored in the refrigerator expired on Nov. 17 which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 11/22/2024 Plan of Correction Deficiency cleared during visit, DSP Supervisor threw the expired gallon of milk from the refrigerator.
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the Administrator did not comply with the section cited above in that the coating on the bathtub in bathroom #1 was chipping and worn out which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 12/04/2024 Plan of Correction Administrator agreed to have the bathtub recoated or refinished and will send proof/pictures to CCL/LPA by POC due date.
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations conducted by LPA alongside with staff, observations were observed of: Hallway Bathroom - water stains / marks , brown and black spots observed on the wall and ceiling and stains and cracks observed on the door casing frame, and paint coming off the wall. Unlevel tiles with missing door threshold between the hallway floor and bathroom fall ,causing a tripping hazard. Hallway- water stain on ceiling and on door casing frame leading to the pantry room. Flooring - uneven, piling and indented and cracked titles in dining room, living room and in pantry room. Room #2- Ceiling water stains and broken door casing frame. Kitchen Cabinets- three drawers are not on track, unleveled and not sturdy. The licensee did not comply with the section cited above in 6 out of 6 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023 Plan of Correction Administrator will send LPA Calderon images of repairs done on the floor tiles, door threshold, door frames , kitchen cabinets, walls that need cleaning / repair/ paint by POC dur date 12/29/23.
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
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