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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603227
Report Date: 10/25/2021
Date Signed: 10/25/2021 11:32:41 AM

Document Has Been Signed on 10/25/2021 11:32 AM - 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:WATERS PLACEFACILITY NUMBER:
198603227
ADMINISTRATOR:WATERS, LUTHERFACILITY TYPE:
735
ADDRESS:2177 WHITE STTELEPHONE:
(626) 696-3910
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 3CENSUS: 3DATE:
10/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Luther Waters - Administrator TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA met with Luther Waters and explained the reason for the visit.

Facility is licensed to serve one (1) ambulatory and two (2) non-ambulatory clients between the ages of 18 - 59 years old. The home is equipped with a sprinkler system and interlace smoke/carbon detector throughout the facility which were tested and working properly. The home has a kitchen, a living room, a dining room, 3 bedrooms, 2 bathrooms, a back yard, front porch, and a detached garage. There are no large bodies of water in the facility.

LPA Flores tour the facility with Luther Waters - administrator and observed the following:
Living room has a glass covered and seal fireplace. Kitchen has sufficient food supplies at least 2 day supplies of perishables and 7 days non-perishables. Sharps and cleaning supplies are under a magnetic lock under the sink and a cabinet above the washer and dryer. A bug spray was observed in an unlock cabinet and 3 screwdrivers were observed in an unlock cabinet. Medication is kept under a magnetic lock above the refrigerator. All bedrooms have all furniture, bedding, and sufficient lighting. Bathrooms are in working condition water temperature was tested at 11.5 degrees F in both, which is under the required 105 - 120 degrees F.

Facility is following COVID 19 recommendations regarding screening visitors, staff, and clients. Facility has placed a request with Department of Public Health to obtain N95 Fit testing. Signs are posted throughout the facility. Handwashing signs are posted by the sinks, and available hand soap, paper towels were observed. PPE supplies were observed facility is to obtain additional gloves and surgical mask.

Deficiency was given during this visit under Title 22 Regulations. Exit interview was conducted with Luther Waters administrator and a copy of this report, 809D, Technical Advisory Note, and appeal rights were given.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2021
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 10/25/2021 11:32 AM - It Cannot Be Edited


Created By: Mary G Flores On 10/25/2021 at 10:54 AM
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: WATERS PLACE
FACILITY NUMBER: 198603227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed bug spray and screwdrivers in the kitchen cabinet/drawer unlock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2021
Plan of Correction
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Administrator removed the items during the visit, no further action is required. Deficiency cleared.
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:Rebecca Orendain
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2021


LIC809 (FAS) - (06/04)
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