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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603149
Report Date: 05/12/2026
Date Signed: 05/12/2026 04:17:02 PM

Document Has Been Signed on 05/12/2026 04:17 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
MONTEREY PARK ASC, 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:
05/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:06 PM
MET WITH:Idelfonso Romero Hernandez, DSPTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by DSP (Direct Support Professional), Idelfonso Romero Hernandez, and LPA explained the purpose of the visit. Administrator Isaac Oluoch arrived shortly after and assisted LPA explained the purpose of the visit. The Administrator assisted 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.

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. The facility has an updated 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 four (4) client bedrooms, two (2) client bathrooms, one (1) staff bathroom, a living room, kitchen, dining area, backyard, and a detached garage. LPA 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. [Continue to LIC809-C]
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WASHINGTON HOME
FACILITY NUMBER: 198603149
VISIT DATE: 05/12/2026
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Physical Plant/Environment Safety [Cont.]: Bathrooms have non-skid materials and contain hygiene supplies including liquid soap, paper towels, and toilet paper. Extra linens and towels were observed in the cabinet. 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 in the kitchen cabinet and inaccessible to clients. There is (1) fire extinguisher that is fully charged and last inspected on 03/30/2026. Carbon monoxides were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured between 105.2 degrees F and 115.9 degrees F which is within the required 105-120 degrees Fahrenheit.

Operational Requirements: Fire clearance for four (4) clients is in place. Liability Insurance and Surety Bond are valid and in place. Fire Drill was conducted on 02/17/2026 and Earthquake/Disaster Drills was last conducted on 03/02/2026.

Staffing: A total of eleven 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: LPA reviewed the Admin and four (4) staff files which included personnel record, health screening, TB test results, criminal background clearance, Employee Rights, valid CPI training, and valid 1st Aid/CPR/AED training. Administrator certificate is valid and will expire on 03/21/2028. Based on record review, Administrator’s file has the updated HIV and TB training.

Client Records-Incident Reports: LPA reviewed all four (4) client files that include face Sheet, Admission Agreement, Physician's Report (including TB and Ambulatory Status), Individual Program Plan (IPP), Appraisal Needs and Services Plan, Safeguard For Property/Valuables and Clients Personal Rights.

Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services and access to the facility phone to all clients. LPA attempted but was not able to interview the clients as they are all nonverbal.

[Continue to LIC809-C]

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WASHINGTON HOME
FACILITY NUMBER: 198603149
VISIT DATE: 05/12/2026
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Food Service: LPA toured the kitchen which appeared clean and the appliances and fixtures functional. The facility kitchen was observed to be clean at the time of inspection. 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 no clients with modified diets residing at this facility. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for four (4) clients 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, no clients at this home has an restricted health condition.

Disaster Preparedness: The facility has an updated Emergency Disaster Plan and at least two (2) relocation sites. Facility maintains documentation of the required emergency drills.

Emergency Intervention: Not applicable. Facility does not use restraints or seclusion.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit interview was held and a copy of this report was provided to the Administrator, Isaac Oluoch.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC809 (FAS) - (06/04)
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