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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603534
Report Date: 12/10/2024
Date Signed: 12/10/2024 03:48:47 PM

Document Has Been Signed on 12/10/2024 03:48 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/
DIRECTOR:		PEGGY PAYNE WALTERSFACILITY TYPE:
735
ADDRESS:59 WEST WASHINGTON BLVD.TELEPHONE:
(626) 791-5290
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 4DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Alicia Walters - Administrator/Licensee
Norma Loya - Co-Administrator/Supervisor		TIME VISIT/
INSPECTION COMPLETED:
03:46 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Martha Garcia Ortega, DSP I & II and explained the purpose of today's visit. Shortly after, the Administrator Alicia Walters and Co-Administrator, Norma Loya arrived and assisted LPA. The facility is licensed to serve developmentally disabled adults ages 18-59 years old. Services provided by Frank D. Lanterman Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff are adhering to infection control requirements. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan.
Physical Plant & Environment Safety: This facility is a 2 story home consists of kitchen, dining room, living room, (6) client bedrooms, (2) bathrooms, laundry area, detached garage, side yard with seating and backyard. Currently, there is construction going on inside the home, flooring will be replaced and wiring needs to be upgraded to install central air and heating. Administrator will send an incident report regarding the on-going construction. Currently, there are (4) clients residing in the home. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Smoke alarms and carbon monoxide were tested and operable. Laundry area is next to the kitchen area. Knives, cleaning solutions, and disinfectants are locked and inaccessible to client. There are no firearms or weapons stored at the facility. Water temperature readings measured were not within the required 105 - 120 degrees Fahrenheit. At 1pm, hot water supply readings measured at 140.6 deg F in bathroom #1 and 135.6 deg F in bathroom #2. Exit doors are free of any obstruction and there are no pools or large bodies of water. Small backyard was inspected and side yard has a shaded area and sitting area.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Liability Insurance policy is valid and expires on 01/01/2025. Surety bond is valid with a bond amount of $4000 and expires on 12/01/2028. Co-administrator stated that the emergency fire and earthquake drills are conducted every 3 months. Last Fire Drill was conducted on 11/11/2024, and earthquake drill was last conducted on 11/13/2024.
*****Refer to LIC 809C for the continuation of this report.*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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
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: 12/10/2024
NARRATIVE
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Staffing: A total of ten (10) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Administrator's certificate is pending and has expired on 10/02/2024. Administrator showed a proof that renewal was sent to CDSS on 08/08/2024. Administrator has valid HIV/AIDS Training certificate.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed (3) staff files including the Administrator. Proof of staff training, health clearance, and vaccinations are current.
Client Rights-Information: Client personal rights are posted. Facility provides internet service and phone to the clients.
Client Records-Incident Reports: LPA reviewed (4) client files. Client files are maintained at the facility. Admission Agreement, Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Food Service: There is sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. The food is properly stored in the refrigerator. There are no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas.
Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for (4) clients. The facility uses TheraP to document medications given. Medications are administered as prescribed by the Physician.
Incidental Medical Services: Per Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. LPA did not observe evacuation chair at the stairwell.
Emergency Intervention: Not-Applicable.

Deficiencies cited on the attached LIC809-D.
Exit interview, appeals rights and a copy of this report was provided to Administrator, Alicia Walters.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/10/2024 03:48 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/10/2024 at 02:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WALTERS HOME
FACILITY NUMBER: 197603534

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in that LPA checked the hot water temperature and readings did not measure within the required 105 - 120 degrees Fahrenheit. At approximately 1pm, hot water supply readings measured at 140.6 deg F in bathroom #1 and 135.6 deg F in bathroom #2 which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 12/11/2024
Plan of Correction
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Administrator agreed to send a 7-day log of the hot water temperature measured in the am & pm. Administrator to submit the completed log to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/10/2024 03:48 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/10/2024 at 02:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WALTERS HOME
FACILITY NUMBER: 197603534

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview, the licensee did not comply with the section cited above in that there is no evacuation chair located in the main stairwell of the facility, which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 12/18/2024
Plan of Correction
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Licensee/Administrator is to ensure that an evacutation chair will be located in the stairwell of the facility at all times. Administrator is to obtain an evacuation chair and send photo and purchase receipt to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
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