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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603149
Report Date: 08/08/2023
Date Signed: 08/08/2023 02:25:36 PM

Document Has Been Signed on 08/08/2023 02:25 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WASHINGTON HOMEFACILITY NUMBER:
198603149
ADMINISTRATOR:DIXON, PAMELAFACILITY TYPE:
735
ADDRESS:475 W WASHINGTON BLVDTELEPHONE:
(213) 361-2792
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 4CENSUS: 4DATE:
08/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:DSP- Kimberly 'Kim' Nephew TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an annual required visit. LPA met with DSP worker Kimberly Nephew and explained the reason for the visit. LPA used the CARE tool to evaluate the facility. LPA observed the physical plant, reviewed (4) clients' medications and records and (5) staff records, observed the food supply, and conducted interviews. The facility cares for adults with intellectual disabilities and is vendorized by Frank. D. Lanterman Regional Center as a Level 4 facility.

LPA alongside with Staff Kim Nephew toured all four client bedrooms. All bedrooms are private rooms. The rooms have the required bed, bedframe, linen, dresser, light, and closet space. All 3 bathrooms were inspected, one is a staff bathroom. The hot water measured 108- 120 F which is within the regulation requirements. There were no toxic chemicals accessible to clients, chemicals are locked under the kitchen sink and garage. Extra linen and towels located in staff bathroom. The kitchen was inspected and there is sufficient perishable and non-perishable food for clients in care. All the appliances are clean and are operating properly. The detached garage (kept locked) has additional food, staff and client files and is used for storage. The common areas include the living room and dining area. These areas are clean and have the required furniture. There are cameras in the common areas only. Backyard was observed to be clean, shaded area was observed and no large bodies of water observed. Client files were reviewed and have appropriate documentation. Staff files were reviewed to confirm appropriate documentation, health screenings and clearances. Health screening not in staff file for Staff #4, deficiency was cited see LIC809-D . All clients' medications were reviewed. Medications are documented properly using an application and given as prescribed .LPA interviewed (2) staff and attempted (4) client interviews, (3) clients non-verbal and (1) at day program.

Fire extinguishers observed to be charged, smoke detector is interconnected with the carbon monoxide which were tested and operable. Fire Drill conducted 6-22-23. Administration Certificate: Expires 10-16-2024.

Per California Code of Regulations, Title 22, the deficiency cited is documented on the attached 809D. A copy of the report and appeal rights were provided. An exit interview held with DSP Kimberly Nephew.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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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Document Has Been Signed on 08/08/2023 02:25 PM - It Cannot Be Edited


Created By: Ashley Calderon On 08/08/2023 at 02:07 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: WASHINGTON HOME
FACILITY NUMBER: 198603149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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During today's visit LPA review 5 staff file, LPA reviewed and observed staff #4 employee file, Health Screening form LIC503 not in staff file. Interview with Staff #4 stated not having the form provided for Physician to complete. Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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Administrator will have staff #4 obtain a Health Screening LIC 503,once completed by the doctor facility will send a copy of the form to LPA Calderon by POC due date of 9/01/23. Administrator will place a copy in staff #4 file.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


LIC809 (FAS) - (06/04)
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