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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603534
Report Date: 12/07/2023
Date Signed: 12/07/2023 12:23:31 PM

Document Has Been Signed on 12/07/2023 12:23 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: 4DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Carlos Hernandez - CaregiverTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Carlos Hernandez (Caregiver) and Juan Mendoza-Alvarez (Administrator) and explained the reason for the visit. The facility is licensed to serve 6 ambulatory clients ages 18-59. Facility currently has 4 ambulatory clients serviced by Lanternman Regional Center.

The facility is a two-story home located in a residential area in Pasadena, Ca. A tour of the facility includes: living room, dining room, den, kitchen (under construction – already reported to Licensing), laundry area, linen closet, 6 bedrooms (one bedroom is an office and one bedroom is being utilized as kitchen during construction) 2 bathrooms, detached garage, front yard, back yard and basement.

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.


Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are centrally stored yet readily available for clients. The hot water temperature in both client bathrooms were tested and within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Facility is undergoing repairs in kitchen making the kitchen inaccessible to clients. Stove and microwave in working condition and dining area available, one bedroom on second floor being utilized as food storage and extra dining area.
(continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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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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: WALTERS HOME
FACILITY NUMBER: 197603534
VISIT DATE: 12/07/2023
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Operational Requirements: The facility maintains an approved fire clearance and conduct regular fire/earthquake drills. Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained electronically, LPA reviewed 4 staff files during today’s visit with no issues. Each file reviewed have criminal record clearance, current First Aid/CPR/AED/CPI and sufficient on-going training. Administrator Juan Mendoza-Alvarez certificate expires on 06/08/24.
Client Rights-Information: The facility does not have any clients that require postural supports. Facility provides internet and telephone landline for the clients.
Client Records-Incident Reports: Client files are maintained electronically and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed and is under construction, dining area in living room and in upstairs bedroom is being utilized during construction, Licensing was notified of renovations. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed 3 clients medications and there were no issues observed. (1 client is currently in the hospital)
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills. The last Fire/Emergency Drill was conducted on 09/14/23.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.
  • LPA conducted 2 staff interviews and 0 client interviews as clients were at day program during visit.
  • Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays’ visit.
  • Exit interview was held and a copy of the report was provided to Administrator Juan Mendoza-Alvarez.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC809 (FAS) - (06/04)
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