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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603149
Report Date: 06/07/2024
Date Signed: 06/07/2024 03:39:22 PM

Document Has Been Signed on 06/07/2024 03:39 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:
06/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:52 PM
MET WITH:Raiko Vides - Direct Support Professional I (DSP I) TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiencies visit in conjunction with Complaint Control # 28-AS-20240430120133. The purpose of this visit is to issue a citation for a deficiency observed during the course of the complaint investigation. LPA met with Raiko Vides, Direct Support Professional I (DSP I) and explained the purpose of the visit. Staff Vides stated that the Administrator is unavailable to assist as she is out of town.

During the complaint visit on 5/07/2024, LPA conducted a tour of the facility, focusing on C1’s bedroom, obtained client/ staff roster, and documents in reference to Client #1. During the facility tour, LPA observed a helmet inside the closet of Client #1 (C1). While conducting interviews and clients file review, LPA observed that licensee/administrator did not submit nor have an exception granted for use of helmet as a restraint device for C1. Interviewed staff stated that C1 uses a helmet as a protective device which do not prohibit C1's mobility but to protect C1 from self injurious behavior. The Administrator agreed to submit the exception to Licensing (CCLD).

Pursuant to Title 22, California Code of Regulations (CCR), deficiency was cited on the attached 809-D.
An exit interview was conducted, and a copy of this report along with the appeals right were provided to Raiko Vides - Direct Support Professional I.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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 06/07/2024 03:39 PM - It Cannot Be Edited


Created By: Bennette Pena On 06/07/2024 at 02:14 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: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2024
Section Cited
CCR
80072(a)(8)(F)(1)

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80072...Personal Rights....(a) Except for .... each client shall have personal rights which include..(8) Not to be placed in any restraining device. Postural supports may be used... (F) Protective devices including,.... helmets,....which do not prohibit a client's mobility.... are not to be considered restraining devices ..... Protective devices may be used if they are approved in advance by the licensing agency ....1. All requests to use protective devices shall be in writing..., in order to evaluate the request.
This requirement is not met as evidenced by:
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Administrator will submit an exception request for protective helmet for C1 along with the required documents to CCL/LPA by POC due date.
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Facility has been using a helmet as a protective device for C1 however Administrator did not submit an exception request for protective helmet for C1.
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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: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024


LIC809 (FAS) - (06/04)
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