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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603227
Report Date: 10/20/2022
Date Signed: 10/20/2022 11:55:19 AM

Document Has Been Signed on 10/20/2022 11:55 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:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Cori Waters - Staff
Luther Waters - Administrator 		TIME COMPLETED:
10:45 AM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, medication, and food review. LPA met with Cori Waters - staff 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 conducted a tour with Luther Waters administrator and observed the following:
Living room has a cover fireplace, living/dining room allows for social distance. Kitchen is clean, sufficient food was observed for at least 2 days of perishables and 7 days of non-perishables Refrigerator's door handle was observed missing. Cleaning supplies, medication, and sharps lock in kitchen's cabinets. Laundry area with lock cabinet for supplies. 3 bedrooms were observed to have required furniture and bedding supplies. Bedroom #1 lights were not working a small lamp provided and in working condition. Bedroom #3 closet door observed out of rails and against the wall. Bathrooms were observed in working condition and water temperature was tested as follow bathroom #1 was tested at 106.3 degrees F., and bathroom #2 was tested at 111.3 degrees F., which is within the required 105-120 degrees F. Medication for 2 clients and files for 3 clients were reviewed and files for 2 staff were reviewed. Administrator certificate was observed for Luther Waters #6016539735 exp 5/31/24.

Deficiencies were noted on LIC 809D per Title 22.

Exit interview was conducted with Luther Waters and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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 10/20/2022 11:55 AM - It Cannot Be Edited


Created By: Mary G Flores On 10/20/2022 at 10:41 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: 10/20/2022

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 licensee did not comply with the section cited above in refrigerator's door handle is missing and bedroom #1 lights are not working which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2022
Plan of Correction
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Administrator provided LPA work orders for items during visit and will provide the department with pictures of repairs by POC due date 11/3/22.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022


LIC809 (FAS) - (06/04)
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