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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603534
Report Date: 11/04/2022
Date Signed: 11/04/2022 12:56:54 PM

Document Has Been Signed on 11/04/2022 12:56 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:WALTERS HOMEFACILITY NUMBER:
197603534
ADMINISTRATOR:PEGGY PAYNE WALTERSFACILITY TYPE:
735
ADDRESS:59 WEST WASHINGTON BLVD.TELEPHONE:
(626) 791-5290
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 5DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Martha Garcia Ortega/S-1 and Juan Mendoza Alvarez (Assistant Administrator)/S-2TIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPAs met with Martha Garcia Ortega/S-1 and explained the purpose of today's visit. Juan Mendoza Alvarez (Assistant Administrator/S-2) arrived at approximately 8:50 A.M..

This home is a two story facility which consists of a living room, kitchen, dining room, laundry room/small area, (6) bedrooms (2 bedrooms downstairs and 4 bedrooms upstairs) and (2) bathrooms (1 downstairs and 1 upstairs).

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance. Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed.
  • Hygiene supplies observed.
  • There are no clients that require incontinence supplies.
  • Restrooms have liquid hand soap and electric hand dryers. Hand washing signs observed.
  • Food supply (perishable for 2 days and non-perishable foods for 7 days) observed.
  • Medications reviewed for C-1 through C-4.
  • Per S-2, C-1 through C-4 have the COVID-19 vaccine and booster.
  • Per S-2, all (7) staff have the COVID-19 vaccine and booster.
  • Staff responsible for direct care and supervision were wearing masks.
  • Clients were socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and appeal rights were provided to Juan Mendoza Alvarez (Assistant Administrator/S-2)

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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