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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603149
Report Date: 05/07/2024
Date Signed: 05/07/2024 04:27:49 PM

Document Has Been Signed on 05/07/2024 04:27 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:WASHINGTON HOMEFACILITY NUMBER:
198603149
ADMINISTRATOR/
DIRECTOR:		DIXON, PAMELAFACILITY TYPE:
735
ADDRESS:475 W WASHINGTON BLVDTELEPHONE:
(213) 361-2792
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 4CENSUS: 4DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Melinda Pippens - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPAs were met by Kimberly Nephew, DSP I and Pamela Martin, DSP I and explained the purpose of the visit. At 9:45am, Administrator Melinda Pippens arrived and assisted LPAs with the visit. The facility is licensed to care for (4) ambulatory Developmentally Disabled Adults ages 18 through 59 of which (2) may be non ambulatory in bedrooms 3 & 4. Facility is approved for delayed egress on exterior gate only. Facility is a level 4I and serviced by Frank D. Lanterman Regional Center.
LPAs 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. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.
Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood, contains a total of (4) client bedrooms, (3) bathrooms, a living room, kitchen, dining area, backyard, and a detached garage. LPAs observed a ring buzzer with audio on the front door and the back door. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. LPAs observed holes in the walls in bedrooms #2 & #3 and the exhaust fan in bathroom #1 is broken and uncovered. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and there were no debris or any obstructions. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. There are (3) fire extinguishers without tags or proof of purchase. Administrator purchased new fire extinguishers and provided proof of purchase to LPAs. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105-120 degrees Fahrenheit.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been submitted to CCL. A fire clearance for (4) clients is in place. Surety Bond is valid with bond amount of $3000. Fire Drill and Earthquake/Disaster Drills were last conducted on 06/22/2023 and 07/18/2023 respectively.*****REPORT CONTINUED ON LIC809-C****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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 5
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: WASHINGTON HOME
FACILITY NUMBER: 198603149
VISIT DATE: 05/07/2024
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.
Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 10/16/2024.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. (2) clients have their own personal cell phone and (2) have their own tablet/IPad. LPAs were not able to interview the clients as they are all non verbal.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. There are (2) clients with special diets residing at this facility. LPAs observed cleaning supplies, toxic substances were stored next to the food supplies in the detached garage. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C4 to confirm medication is given as prescribed and is documented properly. The facility uses TheraP to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed and locked in a bin.
Incidental Medical Services: Per the Administrator, zero (0) client at this home has restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not applicable.

Deficiencies cited and Technical assistance issued. Exit interview held and a copy of this report was provided to Melinda Pippens, Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/07/2024 04:27 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/07/2024 at 02:13 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: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator did not comply with the section cited above in that Fire Drill and Earthquake/Disaster Drills were last conducted on 6/22/2023 and 07/18/2023, respectively which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 05/08/2024
Plan of Correction
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Administrator will ensure that fire drills are conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. Administrator will submit copies of the drills training to CCL/LPA by POC due date,
Type A
Section Cited
CCR
80075(a)
Health-Related Services
(a) The licensee shall ensure that each client receives first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the Administrator did not comply with the section cited above in that LPAs observed that C1 did not take one of the prescribed medications, Oxcarbazepine 300 mg tab on 5/07/2024 because Administrator was not able to obtain refill authorization from doctor until the afternoon of 5/07/2024 which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 05/08/2024
Plan of Correction
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Licensee shall provide additional training to all Staff responsible for medication assistance, refill process and provide proof to CCL/LPA by POC due date.

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: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/07/2024 04:27 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/07/2024 at 02:13 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: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 LPAs observed holes in the walls in bedrooms #2 & #3 and the exhaust fan in bathroom #1 is broken and uncovered which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/17/2024
Plan of Correction
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Administrator will submit photos of the fixed holes in the walls and exhaust fan in the bedrooms and bathroom to CCL/LPA by POC due date..
Type B
Section Cited
CCR
80076(a)(16)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (16) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

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 LPAs observed cleaning supplies, toxic substances were stored next to the food supplies in the detached garage which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/17/2024
Plan of Correction
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Administrator will send photos as proof that the cleaning supplies, toxic matreials are stored in a separate area from the food supplies. Photos to be submitted to CCL/LPA by POC due date.
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: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
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